Accepted Manuscript

Patient dissatisfaction following total knee arthroplasty: A systematic review of the

literature

GD Rajitha Gunaratne, MBBS, Dylan N. Pratt, BEng, Joseph Banda, BEng, Daniel
P. Fick, MBBS (Hons), FRACS, ARGG, Riaz J.K. Khan, BSc (Hons), MBBS (Lon),
FRCS (Tr & Orth), FRACS, PhD, Brett W. Robertson, PhD
PII: S0883-5403(17)30619-8
DOI: 10.1016/j.arth.2017.07.021
Reference: YARTH 56001

To appear in: The Journal of Arthroplasty

Received Date: 11 January 2017

Revised Date: 20 June 2017
Accepted Date: 14 July 2017

Please cite this article as: Gunaratne GR, Pratt DN, Banda J, Fick DP, Khan RJK, Robertson BW,
Patient dissatisfaction following total knee arthroplasty: A systematic review of the literature, The Journal
of Arthroplasty (2017), doi: 10.1016/j.arth.2017.07.021.

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 ACCEPTED MANUSCRIPT

Patient dissatisfaction following total knee

arthroplasty: A systematic review of the literature

GD Rajitha Gunaratne a,b, Dylan N. Pratt a,b, Joseph Banda a,b, Daniel P. Fick a,b,c,d,e, Riaz J.K. Khan a,b,c,d,e,f

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, Brett W. Robertson a,b,d,e

a) Curtin University, Kent Street, Bentley, WA, 6102, Australia (+61892667192)

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b) Australian Institute of Robotic Orthopaedics, 2 Centro Avenue, Subiaco, WA, 6008, Australia
(+61409537537)
c) The Joint Studio, Hollywood Medical Centre, 85 Monash Avenue, Nedlands, WA, 6009, Australia

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(+6193863933)
d) The Virtual Centre for Advanced Orthopaedics, 1155 Union Circle, Denton, Texas 76203, United
States of America (+9405653260)

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e) University of North Texas, 1155 Union Circle, Denton, Texas 76203, United States of America
(+762035017)
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f) University of Notre Dame, 9 Mouat Street, Fremantle, WA, 6959, Australia (+6194330555)
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GUNARATNE, G D Rajitha FICK, Daniel

MBBS MBBS (Hons), FRACS, ARGG

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gunaratne.rajitha@gmail.com danfick@gmail.com
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KHAN, Riaz ROBERTSON, Brett

BSc (Hons), MBBS (Lon), FRCS (Tr & Orth), FRACS, PhD
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PhD

rjkkhan@gmail.com brett@airo.net.au
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PRATT, Dylan N BANDA, Joseph

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BEng BEng

dylan.pratt@student.curtin.edu.au bandajoseph92@gmail.com
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Abstract

Background: Dissatisfaction following total knee arthroplasty is common. Approximately twenty

percent of patients’ report dissatisfaction following primary total knee arthroplasty (TKA). This
systematic literature review explores key factors affecting patient dissatisfaction following TKA.

Methods: Six literature databases published between 2005 to 1st January 2016 were searched using
three key search phrases. Papers were included if the study investigated patient dissatisfaction in

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primary unilateral or bilateral TKA. Information from each article was categorised to the domains of
socioeconomic, preoperative, intraoperative and post-operative factors affecting patient
dissatisfaction.

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Results: This review found patient dissatisfaction pertains to several key factors. Patient
expectations prior to surgery, the degree of improvement in knee function and pain relief following

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surgery were commonly cited in the literature. Fewer associations were found in the socioeconomic
and surgical domains.

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Conclusion: Identifying who may be dissatisfied after their TKA is mystifying, however we note
several strategies that target factors whereby an association exists. Further research is needed to
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better quantify dissatisfaction, so that the causal links underpinning dissatisfaction can be more fully
appreciated and strategies employed to target to them.
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 ACCEPTED MANUSCRIPT

1 Patient dissatisfaction following total knee

2 arthroplasty: A systematic review of the literature
3 Abstract

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4 Background: Dissatisfaction following total knee arthroplasty is common. Approximately twenty
5 percent of patients’ report dissatisfaction following primary total knee arthroplasty (TKA). This
6 systematic literature review explores key factors affecting patient dissatisfaction following TKA.

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7 Methods: Six literature databases published between 2005 to 1st January 2016 were searched using
8 three key search phrases. Papers were included if the study investigated patient dissatisfaction in

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9 primary unilateral or bilateral TKA. Information from each article was categorised to the domains of
10 socioeconomic, preoperative, intraoperative and post-operative factors affecting patient
11 dissatisfaction.

12
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Results: This review found patient dissatisfaction pertains to several key factors. Patient
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13 expectations prior to surgery, the degree of improvement in knee function and pain relief following
14 surgery were commonly cited in the literature. Fewer associations were found in the socioeconomic
15 and surgical domains.
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16
17 Conclusion: Identifying who may be dissatisfied after their TKA is mystifying, however we note
18 several strategies that target factors whereby an association exists. Further research is needed to
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19 better quantify dissatisfaction, so that the causal links underpinning dissatisfaction can be more fully
20 appreciated and strategies employed to target to them.
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21 Key Words: Primary, Total knee arthroplasty, Total knee replacement, Systematic review,
22 Satisfaction, Dissatisfaction
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23 1. Introduction

24 Dissatisfaction is the state or attitude of not being satisfied ; discontent; displeased, or a particular
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25 cause or feeling of displeasure or disappointment (1). Total knee arthroplasty (TKA) is generally a
26 successful and cost-effective treatment for improving pain and function in patients with arthritis(2).
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27 However, only around eighty percent of patients are satisfied with overall outcome of surgery (3-6).
28 The ratio of one dissatisfied patient for every five TKAs has persisted over the last decade, despite
29 substantial improvements in surgical technologies and treatments (3, 5). Identification of the causes
30 of patient dissatisfaction are important in terms of patient selection for TKA, but also to help
31 dissatisfied patients with their specific problems(7). Hence, there is a substantial interest to explore
32 and understand factors that influence patient dissatisfaction (8).

33 Our understanding of dissatisfaction in TKA is limited by 2 factors; first, a paucity of targeted

34 research, and second, limitations in the way we measure dissatisfaction. Satisfaction following TKA is

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35 commonly measured using a Likert scale whereby patients can respond as feeling either “very
36 satisfied, satisfied, neutral, dissatisfied or very dissatisfied” with the outcome of surgery.
37 Dissatisfaction is assumed if a patient does not report being satisfied, however Frederick Herzberg's
38 two factor theory (9, 10) tells us that satisfaction and dissatisfaction are not opposites of each other.

39 For Orthopaedic Surgeons and the clinical team, it is an ongoing challenge to understand and
40 therefore assist their dissatisfied patients. While Orthopaedic literature investigating patient
41 satisfaction is available, research explicitly exploring patient dissatisfaction is more limited.

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42 Occasionally, dissatisfaction is reported by TKA patients who reportedly have a physically well-
43 functioning knee. This disparity between patient and clinician outcome ratings is well documented in

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44 the literature (3, 11, 12) and highlights the inherently subjective and undoubtedly multifactorial
45 nature of dissatisfaction (13, 14).

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46 This literature review groups common factors affecting patient dissatisfaction following primary TKA
47 into four main themes: sociodemographic, preoperative, intraoperative and postoperative domains.
48 These are discussed in relation to managing patient care with the aim of reducing dissatisfaction
49

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rates. AN
50 2. Materials and methods

51 2.1 Literature and database searches

52 Google Scholar, Cochrane library, Medline, Embase, CINAHL and PubMed databases were searched
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53 using a combination of three keywords ‘‘dissatisfaction’’, ‘‘satisfaction’’ and ‘‘total knee’’.

54 References of studies that met inclusion criteria were additionally considered.
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55 2.2 Literature selection

56 Two reviewers assessed studies against the inclusion criteria first by examination of title, abstract,
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57 and then the full text. When it was unclear from the abstract whether the paper met inclusion
58 criteria, the entire paper was included in the study. If still unclear our senior authors were consulted.
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59 Inclusion criteria were:

60 ● The study focused on primary TKA.
61 ● The article considered unilateral or bilateral primary TKA.
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62 ● The study had been published between 1st January 2005 to 1st January 2016.
63 ● The study analysed dissatisfaction.
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64 ● English language

65 2.3 Data extraction

66 For each paper meeting inclusion criteria, the full reference, type of study, sample size and post-
67 operative follow-up duration were extracted, along with core information summarising key findings
68 from each paper. The two reviewers each categorised findings and these were summarised and
69 tabulated. Figure 1 shows flowchart for article selection.

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70 3. Results

71 Factors positively associated with dissatisfaction are listed in Table 1 – Table 4 in chronological
72 order.

73 3.1 Sociodemographic Factors

74 Four studies (Table 1) reported the association between dissatisfaction and sociodemographic
75 factors. TKAs are typically performed on elderly patients (15). Conflicting results have been

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76 observed with age and its association with dissatisfaction. Bourne et al. (3) found that advanced age
77 was associated with dissatisfaction while another study found that each year of age decreased the
78 odds of dissatisfaction by four percent (16). Scott et al. (17) found age did not predict dissatisfaction.

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79 It is possible that physiological age may be more predictive than chronological age, as fitter and
80 more active patients have higher expectations (17).

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81
82 Bourne et al. (3) found that patients who lived alone were more likely to be dissatisfied and felt this
83 may be confounded by associated lower mental health scores. The Australian Institute of Family
84

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Studies investigated the consequences of living alone found negative associations with life
85 satisfaction (18).
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86
87 Jacobs et al. (12) found that African American patients were three times more likely to be
88 dissatisfied with their surgery than Caucasian patients. Studies have identified higher revision rates
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89 (19) and need for manipulation under anesthesia (20) in African American patients. These
90 complications may explain in part, the higher dissatisfaction rates.
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92 Kim et al. (7) found dissatisfied TKAs to have smaller mean body weight and Body Mass Index (BMI)
93 in their univariate analysis. Other studies investigating BMI and additional sociodemographic
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94 variables including sex, education, household income, employment, ability to perform ADLs and
95 insurance coverage (3, 12, 17, 21-24) did not show significant correlation.
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97 3.2 Preoperative Factors

98 Eight studies (Table 2) reported the association between dissatisfaction and preoperative factors.
99 Studies which explored preoperative factors found that mental health, patient reported functional
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100 measure, pain and the patient’s functional ability influence dissatisfaction. TKA patients were more
101 likely to be dissatisfied if they were scheduled for surgery from a reassessment in comparison to an
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102 initial patient consultation (25). Similarly, Desmeules et al.(26) observed a delay in surgical treatment
103 of knee osteoarthritis negatively influenced pain, function and health-related quality of life
104 postoperatively, however dissatisfaction per say was not measured.
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106 Bourne et al.(3) reports a low preoperative Western Ontario and McMaster Universities Arthritis
107 Index (WOMAC) score increases the risk of dissatisfaction by 2.4 times. Similarly other studies also
108 consistently report a link between poor preoperative patient reported outcome measures (PROM)
109 with increased dissatisfaction (3, 7, 16, 17). Association has been drawn between higher knee pain
110 scores, pain in other joints (17) and dissatisfaction (7, 27). Kim et al. (7) suggest that dissatisfied

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111 patients may have higher sensitivity to pain even before surgery. The authors also highlight the
112 importance of excluding other joints as a source of dissatisfaction rather than incorrectly attributing
113 this to the TKA. Scott et al.(17) also examined this, and identified back pain and pain in other joints to
114 be a highly significant predictor of TKA dissatisfaction. Interestingly, in another study it was
115 observed that dissatisfied patients with spinal symptoms became more satisfied with their TKA after
116 their spinal complaint was treated.
117

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118 Jacobs et al.(12) found that patients with less severe degenerative changes were 2.1 times more
119 likely to be dissatisfied. Similarly, Schnurr et al. (28) examined levels of arthritic change. The risk for
120 dissatisfaction was elevated 2.556-fold for arthritis grade III° (p<0.001) and 2.956-fold higher for

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121 grade II° (p=0.001). Other studies (7) have associated dissatisfaction with better preoperative knee
122 range of motion, smaller flexion contracture and larger maximum flexion (3). Nazzal et al. (29) found
123 a lower preoperative maximum walking distance was another significant factor.

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124
125 Poor mental status and depression prior to surgery have been associated with increased
126 dissatisfaction (17) (16). It is widely recognized that depression influences a patient’s perception of

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127 disability and experience of pain (30, 31).
128
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129 3.3 Intraoperative Factors
130 Two studies (Table 3) reported the association between dissatisfaction and Intraoperative factors.
131 Despite the study of several intraoperative factors, few positive correlations were drawn from the
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132 reviewed literature; this covers prosthesis design, implantation methods, surgical techniques and
133 component alignment. As prosthesis technology has evolved, there is an expectation that the quality
134 of the surgery has also improved and thus dissatisfaction should be reduced. Surprisingly, an
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135 association was not found between contemporary TKA implants and decreased patient
136 dissatisfaction (3). No association has been identified with different prosthetic design, cruciate
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137 retention (3, 7) nor variants of fixed or mobile bearing implant design(7) .
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139 Nam et al.(21) compared custom cutting guides versus standard instrumentation to implant the TKA
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140 and found no significant difference in dissatisfaction. A positive association in the implanting
141 technique was found however, when there is less proximal tibial resection (12) and less accurate
142 coronal alignment of the femoral component (16). No correlation was identified with cemented,
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143 uncemented or hybrid fixation (32), patella resurfacing (3, 32), the distal femur resection (12),
144
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number of structures released (12) and if lateral release were performed. Surgical technique also
145 does not appear to have an impact on dissatisfaction including tourniquet use (32), incision (32),
146 removal of fat pad (32) and interestingly, if unilateral or bilateral surgery was performed (7) and who
147 the lead surgeon was (32).
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149 Huijbregts et al. (16) investigated alignment and although coronal component alignment was more
150 accurate in the satisfied group, no significant association was found between alignment and
151 dissatisfaction. Gandhi et al. (33) studied dissatisfaction with knee alignment using a questionnaire
152 preoperatively and at six months postoperatively. They found that patient perception of alignment

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153 correlated poorly with true radiographic alignment and patients dissatisfied with alignment were
154 more likely to incorrectly perceive their alignment.
155
156 3.4 Postoperative Factors
157 Eleven studies (Table 4) reported the association between dissatisfaction and postoperative factors.
158 Multiple postoperative factors have been associated with dissatisfaction. These include lower PROM
159 scores, lower general health scores, increased pain, lower objective functional measures,

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160 complications and expectations not being met.
161
162 A lower Oxford Knee Score (OKS) and smaller improvements in this score have been shown (7, 16,

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163 17, 32) in multiple studies to correlate with dissatisfaction, regardless of the postoperative
164 timeframe at which it was assessed. Similarly, studies have demonstrated that dissatisfied patients
165 had lower postoperative WOMAC scores (3, 23, 34) and in particular the functional sub-score (7, 23,

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166 34).
167
168 Along with lower PROMs of function (17, 22, 32), a relationship has been found with many objective

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169 functional activity tests including stretching, leg strengthening exercises, turning/pivoting, moving
170 laterally, dancing, gardening, maximum walking distance, stairs climbed and squatting (22, 29). The
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171 capacity to perform some of these activities may be confounded by dissatisfied patients having
172 reduced knee movement (7, 12) and stiffness or swelling episodes greater than once a week (22).
173
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174 Not surprisingly, patients who were less active after their knee replacement operation were more
175 likely to be dissatisfied (22). Patients in this group were not as active as they had expected to be, and
176 reported that their knee restricted them from doing activities they wanted to do (22). Unmet
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177 expectations were also one of the biggest predictors of dissatisfaction in a study by Bourne et al. (3).
178 Longer length of hospital stay (17) , presence of a postoperative complication and patients not
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179 willing to have surgery were more prevalent in the dissatisfied group (3).
180
181 General health scores; Short Form 36 (SF36) (34) and Short Form 12 (SF12) scores (17) have also
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182 been scrutinised in dissatisfied patients. A relationship with poor physical health (7) and
183 dissatisfaction is similar to the association of higher pain scores with dissatisfaction in other studies
184 (3, 17, 29, 32). This dissatisfied group was also more likely to have narcotics prescribed at 12 months
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185 following TKA (35) and to use more than one pain medication daily (22).
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187 Interestingly, a clinically good knee does not absolve a patient from dissatisfaction (3, 11, 13, 23).
188 Noble et al. (22) showed that, among patients with no knee symptoms, there was no apparent
189 difference between satisfied and dissatisfied patients in terms of their demographic profile or
190 functional capacity.
191
192 4. Discussion
193 Patients desire an operation that is going to resolve their pain, restore function, and not burden
194 them with residual symptoms(36). The attitudes of patients after surgical treatment is a complex
195 blend of relief, regret, hope, and expectation (22). This literature review investigated multiple

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196 factors believed to impact patient dissatisfaction. These varied and spanned the sociodemographic
197 (BMI, age, living alone and cultural background), Preoperative (Knee function, general health, pain,
198 mental health, pain in other joints and arthritis stage), Intraoperative (Medial compartment and
199 trochlear wear, tibial resection and coronal alignment of femoral component) and postoperative
200 domains (Knee function, pain, swelling, feeling ‘normal’, general health, expectations not met,
201 longer admission and complications).

202 Identifying factors associated with dissatisfaction following TKA enables the surgeon and healthcare

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203 team to address those which may be modifiable, and separating these from sociodemographic
204 variables are beyond the bounds of manipulation. Results of one study suggest that dissatisfaction

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205 may be decreased with a concerted effort to schedule surgery from the initial patient consultation
206 (25), however confounding variables may exist. One could postulate the interplay of additional
207 factors whereby patients with clear indications and benefits were scheduled directly, whereas those

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208 with borderline indications or need of medical fitness evaluations would return for reassessment.
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210 Managing symptoms of dysfunction not directly associated with the knee is a modifiable prep-

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211 operative factor. Optimisiing other health issues preoperatively may in turn improve dissatisfaction.
212 Strategies to minimise negatively correlated factors centers on a holistic care approach; for example,
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213 referring to a dietician to support weight reduction, or social services to assist those living alone.
214
215 Acknowledging factors linked with dissatisfaction can assist educators to appropriately educate
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216 patients and set realistic expectations after TKA (23). Expectations not met has been identified as a
217 contributing factor to dissatisfaction. It has been reported that patients from different countries had
218 different expectations regarding TKA (37). Seng et al (38) identified a demand for higher flexion in
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219 the Asian population. Inappropriate expectations may result from misinterpretation or lack of
220 information regarding the likely results of surgery (37). A targeted discussion should take place
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221 between surgeon and every patient, to identify their individual goals and to educate and formulate
222 reasonable expectations and timelines for these to be reached. These expectations should be
223 modulated based on a variety of factors including patient age, function and cultural beliefs.
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224 Importantly, clinicians need to be weary of keeping in check our own perceptions, and to allow
225 patients to identify and verbalise their own concerns.
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226 Relationships between dissatisfaction and preoperative functional ability, mental health and high
227 pain were highlighted by this review. Individuals displaying one or some of these factors at the
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228 preoperative visit, should be counselled and their satisfaction expectation modulated accordingly. In
229 patients reporting high pain levels, if chronic, central sensitization may relate to post-operative
230 dissatisfaction (39, 40). Early, additional pain management strategies may be warranted.
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232 Although surgical procedures have improved greatly, there has been little translation to decrease
233 levels of dissatisfaction amongst TKAs. Whilst surgeons must continue to strive to achieve a precisely
234 aligned knee, implanted with minimal soft tissue disruption, and to avoid complications, they must
235 also collaborate with their anaesthetic, nursing and physiotherapy colleagues to find ways to
236 maximise pain management and expedite the restoration of function. Patients want a knee that

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237 feels “normal” after their operation (36) but as shown by Noble et al. (22), up to half of dissatisfied
238 patients have residual knee symptoms such as pain, swelling, and stiffness. The limitations of TKR in
239 restoring premorbid function and feeling like a natural knee should be emphasised (17).
240
241 A main limitation of this review was the acceptance of studies lacking rigor in how they defined and
242 assessed dissatisfied TKA patients. The recent literature is devoid of high level evidence, and derives
243 its knowledge base from retrospective group comparisons of dissatisfied verses satisfied patients.

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244 Methodologies of paper in this review utilised a Likert scale alone, and did not ask why each patient
245 was dissatisfied. A further critic lies in the dissection of outcome measures in a way they were not
246 designed, validated or found reliable to report. For example, composite scores of PROMs comprising

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247 of questions on factors such as pain, stiffness and ADLs which are all differently weighted, were
248 fragmented. Additionally, many of the studies based results on self-administered questionnaires,
249 which are particularly prone to bias in that patients who are dissatisfied with their outcome may fail

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250 to respond. Bias also exists when patient understate their response to please the physician or
251 research team. Lastly, the majority of the studies lacked a power analysis. Higher quality of research
252 is needed to identify the causal links underpinning dissatisfaction, and to evaluate the impact of the

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253 suggested in this review.
254
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255 5. Conclusion
256 Approximately twenty per cent of patients’ express dissatisfaction following primary TKA. The
257 authors have explored the literature in terms of sociodemographic, preoperative, surgical and
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258 postoperative factors and their relative impact on dissatisfaction. It appears there is no single
259 leading factor, but rather a series of possibly interrelated factors at play. This review found patient
260 expectations, higher function before surgery, stage of arthritic disease, complications, poor
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261 resolution of pain, and lower improvement in knee function were common in dissatisfied TKA
262 patients. Identifying patients who may be dissatisfied following their TKA in some individuals is
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263 mystifying, however we note several strategies that target factors where an association is suspected.
264
265 Conflicts of Interest
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266 None.

267 References
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268 1. Dictionary CE. 2010 [Available from:

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352 33. R Gandhi JdB, D Petruccelli, M Winemaker. Does patinet perception of alignment
353 affect total knee arthroplasty outcomes? Canadian Journal of Surgery. 2007;50(3):181- 6.

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354 34. Thambiah MD, Nathan S, Seow BZ, Liang S, Lingaraj K. Patient satisfaction after
355 total knee arthroplasty: an Asian perspective. Singapore Med J. 2015;56(5):259-63.

356 35. Franklin PD, Karbassi JA, Li W, Yang W, Ayers DC. Reduction in narcotic use after

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357 primary total knee arthroplasty and association with patient pain relief and satisfaction. J
358 Arthroplasty. 2010;25(6 Suppl):12-6.

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359 36. Hofmann AA, Schaeffer JF. Patient satisfaction following total knee arthroplasty: Is it
360 an unrealistic goal? Seminars in Arthroplasty. 2014;25(3):169-71.

361 37. E A Lingard CBS, I D Learmonth. Patient Expectations Regarding Total Knee

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362 Arthroplasty: Differences Among the United States, United Kingdom, and Australia. The
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363 Journal of Bone & Joint Surgery. 2006;88A(6):1201-7.

364 38. Seng C, Yeo SJ, JL W. Improved clinical outcomes after high-flexion total knee
365 arthroplasty: a 5-year follow-up study. J Arthroplasty. 2011;26:1025-30.
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366 39. Arendt-Nielsen L, Nie H, Laursen MB, Laursen BS, Madeleine P, Simonsen OH, et
367 al. Sensitization in patients with painful knee osteoarthritis. PAIN. 2010;149(3):573-81.
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368 40. Wylde V, Dieppe P, Hewlett S, Learmonth ID. Total knee replacement: Is it really an
369 effective procedure for all? The Knee. 2007;14(6):417-23.
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370 41. Franklin PD, Karbassi JA, Li W, Yang W, Ayers DC. Reduction in Narcotic Use
371 After Primary Total Knee Arthroplasty and Association with Patient Pain Relief and
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372 Satisfaction. The Journal of Arthroplasty. 2010;25(6):12-6.

373 42. Nazzal MI, Bashaireh KH, Alomari MA, Nazzal MS, Maayah MF, Mesmar M.
374 Relationship between Improvements in Physical Measures and Patient Satisfaction in
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375 Rehabilitation after Total Knee Arthroplasty. International Journal of Rehabilitation

376 Research. 2012;35(2):94-101.
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377 43. Jacobs CA, Christensen CP. Factors Influencing Patient Satisfaction Two to Five
378 Years After Primary Total Knee Arthroplasty. The Journal of Arthroplasty. 2014.

379 44. Jacobs CA, Christensen CP, Karthikeyan T. Patient and intraoperative factors
380 influencing satisfaction two to five years after primary total knee arthroplasty. The Journal of
381 Arthroplasty. 2014.

382 45. Thambiah MD, Nathan S, Seow BZX, Liang S, Lingaraj K. Patient satisfaction after
383 total knee arthroplasty: an Asian perspective. Singapore Medical Journal. 2015;56(5):259-63.

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384 46. Huijbregts HJTAM. Prosthetic alignment after total knee replacement is not
385 associated with dissatisfaction or change in Oxford Knee Score. The Knee. 2016.

386
387 Franklin et al.. 2010 (41) Nazzal et al.. 2012 (42) Jacobs et al.. 2014 (43) Jacobs et al.. 2014 (44) Thambiah et al.. 2015 (45) Huijbregts et al.. 2016 (46)

388
389

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Acknowledgement

Dr Iain Murray (I.Murray@curtin.edu.au)

PhD

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Curtin University, Kent Street, Bentley, WA, 6102, Australia (+61892667192)

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Samantha Haebich (samhaebich@hotmail.com)

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BAppSc (Phys)

The Joint Studio, Hollywood Medical Centre, 85 Monash Avenue, Nedlands, WA, 6009,
Australia (+6193863933)


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Table 1: SOCIODEMOGRAPHIC factors associated with dissatisfaction

Sample size :
Type of
Reference Follow Up Sociodemographic Factors
study

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Period

• Lower mean body weight (p=0.035)

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Retrospectiv • Lower body mass index (p=0.002)
Kim et al..
e cohort 473: >1 year
2009 (7)
study

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• Advanced age (p =0.012)
Bourne et Prospective • Lives alone (p=0.013)
1,703: 1 year
al.. 2010 (3) cohort study

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• African American patients were 3.0 times more likely to be
Jacobs et dissatisfied with their surgery than Caucasian patients (OR = 3.0,
Prospective 989: Mean 3.5
al.. 2014 95% CI = 1.5–6.0, P = 0.003)
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cohort study Years
(44)
• At three months postoperatively, age was significant variable (OR
Huijbregts Retrospectiv = 0.96 per year, 95% CI: 0.92 to 1.00, P = 0.038)
230: 3 months
et al.. 2016 e cohort
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& 1 year
(46) study

Western Ontario and McMaster Universities Arthritis Index (WOMAC), Oxford Knee Score
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(OKS), Confidence Interval (CI), Odds Ratio (OR), Physical Component Score (PCS), Mental
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Component Score (MCS), Short Form 12 questionnaire (SF12), Short Form 36 questionnaire
(SF 36).
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Table 2: PREOPERATIVE factors associated with dissatisfaction

Sample size :
Reference Type of study Follow Up Preoperative Factors

PT
Period

• Poorer knee functional score (P = .001)

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• Better knee movement range, less flexion contracture and higher
Kim et al.. Retrospective maximum flexion (p<0.001)
473: >1 year
2009 (7) cohort study • Poorer Physical General Health (p=0.03)

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• Was not a new patient when scheduled for TKA (p=0.047)
• >90° flexion (p=0.022)
Bourne et Prospective
1,703: 1 year • Extreme pain rating in lying or sitting (p<0.0001)
al.. 2010 (3) cohort study

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• Depression (p < 0.001)
• Lower SF12 MCS ((p < 0.001)
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Scott et al.. Prospective • Pain in other joints (p < 0.001)
1217: 1 year
2010 (2) cohort study • Poorer OKS (p=0.014)
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Nazzal et • Lower maximum walking distance (p=0.03)

Prospective
al.. 2012 56: 3 months
cohort study
(42)
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• In comparison to severe arthritis Kellgren Lawrence IV°, the risk

Schnurr et for dissatisfaction was 2.556-fold elevated for arthritis grade III°
Retrospective 1121: 2.8
al.. 2013 (p<0.001) and 2.956-fold higher for grade II° (p=0.001)
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cohort study years mean

(28)

Jacobs et
Prospective 768: 2.8years
al.. 2014 • Greater passive range of motion (p=0.02)
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cohort study mean

(43)
• Patients with less severe degenerative changes were 2.1 times
Jacobs et more likely to be dissatisfied (95% CI = 1.3–3.2, P = .001)
Prospective 989: Mean
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al.. 2014
cohort study 3.5 Years
(44)
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Huijbregts
Retrospective 230: 3 months
et al.. 2016 • Worse OKS (p=0.016)
cohort study & 1 year
(46)

Western Ontario and McMaster Universities Arthritis Index (WOMAC), Oxford Knee Score
(OKS), Confidence Interval (CI), Odds Ratio (OR), Physical Component Score (PCS), Mental
Component Score (MCS), Short Form 12 questionnaire (SF12), Short Form 36 questionnaire
(SF 36).
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Table 3: INTRAOPERATIVE factors associated with dissatisfaction

Sample size :
Reference Type of study Follow Up Intraoperative Factors
Period

PT
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Jacobs et • Less wear at medial femoral condyle (p=0.005), medial tibial
Prospective 989: Mean
al.. 2014 plateau (p=0.009) and trochlear (p=0.02)
cohort study 3.5 Years
(44) • Less proximal tibial resection (p<0.001)

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• Coronal alignment of the femoral component was more
Huijbregts accurate in patients who were satisfied at one year compared
Retrospective 230: 3 months
et al.. 2016 to dissatisfied patients (p=0.045)
cohort study & 1 year
(46)

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(OKS), Confidence Interval (CI), Odds Ratio (OR), Physical Component Score (PCS), Mental
Component Score (MCS), Short Form 12 questionnaire (SF12), Short Form 36 questionnaire
(SF 36).
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Table 4: POSTOPERATIVE factors associated with dissatisfaction

Sample size :
Reference Type of study Follow Up Postoperative Factors

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Period

• Knee did not feel normal (p < 0.0001)

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• Patient feels less active than they did be before the operation (p<0.0001)
• Knee limits desired activities (p<0.0001)
• Stiffness > 1/week (0.0006)
• Swelling > 1/week (0.008)

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Noble et al.. Retrospective • >1 Pain medication per day (0.001)
253: >1 year
2006 (22) cohort study • Some difficulty with activity of daily living (<0.0001)
• Lower functional performance with stretching (p=0.01), leg strengthening
exercises (p=0.0001), turning/pivoting (p=0.005), moving laterally

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(p=0.0003), dancing (p=0.01), gardening (p=0.03), and squatting (p=0.004).
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Baker et al.. Retrospective • Poorer knee functional score (p < 0.001).
9,417: >1 year
2007 (32) cohort study • Higher pain scores (p <0.001).
• Greater knee movement restriction (P < 0.001)
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• Poorer knee function (p=0.004)

• Poorer pain (p=0.007), stiffness (p=0.003) and functional sub-scores
Kim et al.. Retrospective (p<0.001)
473: >1 year • Poorer Physical General Health (p=0.001), role physical (p=0.042), bodily pain
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2009 (7) cohort study

(p=0.001), vitality (p<0.001), social functioning (p=0.045), role emotional
(p=0.027).
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• Poorer knee functional score (p<0.0001)

• Smaller knee functional score improvement (p<0.0001)
• Is not willing to have surgery again (p<0.0001)
Bourne et Prospective
1,703: 1 year • Expectations were not met (p<0.0001)
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al.. 2010 (3) cohort study

• Experienced a complication necessitating hospital admission (p<0.0001)

• Longer hospital stay (p=0.003)

• Poorer 6 month SF12, OKS and smaller improvements in pain and function
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Scott et al.. Prospective

1217: 1 year (p<0.001)
2010 (2) cohort study
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Franklin et • Prescribed narcotics 12 months after TKA (P<0.001)

Retrospective
al.. 2010 6364: 1 Year
cohort study
(41)

• Higher pain scores (p=0.01)

• Lower improvement in pain (p=0.03)
Nazzal et
Prospective • Lower improvement in maximum walking distance (p=0.04)
al.. 2012 56: 3 months
cohort study • Lower number of stairs climbed (p=0.02) and lesser improvement in climbed
(42)
stairs (p=0.03)
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• Poorer WOMAC and subscales
Du et al.. Retrospective • Less improvement in WOMAC total scores and subscales except for stiffness
748: 1 year (p<0.05)
2014 (23) cohort study

• Lower improvement in passive extension (p=0.01)

Jacobs et
Prospective 768: 2.8years • Lower passive flexion and less improvement in passive flexion (p<0.001)
al.. 2014
cohort study mean • Worst pain score and less improvement in pain (p<0.001).
(43)
• Worst functional score and less improvement in functional score (p<0.001)

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Thambiah 103:
Prospective • Lower WOMAC (p=0.040) and WOMAC Function subscore (p=0.028)
et al.. 2015 Minimum 1
cohort study • Lower improvement in SF36 PCS (p=0.004)
(45) Year
• 3 month OKS: OR = 0.88 per OKS point (95% CI: 0.83 to 0.92)

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• Worse 1 year OKS and less improvement in OKS (p<0.001)
Huijbregts
Retrospective 230: 3 months
et al.. 2016
cohort study & 1 year

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(46)

Western Ontario and McMaster Universities Arthritis Index (WOMAC), Oxford Knee Score

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(OKS), Confidence Interval (CI), Odds Ratio (OR), Physical Component Score (PCS), Mental
Component Score (MCS), Short Form 12 questionnaire (SF12), Short Form 36 questionnaire
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(SF 36).
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Figure 1: Flowchart for article selection

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