FUNCTIONAL OUTCOME IN SHORT TERM FOLLOW UP AFTER

TOTAL KNEE REPLACEMENT IN KANDOU HOSPITAL

Rawung Rangga, MD1, Juliandi Tomi,MD1
1 Department of Surgery, Prof Kandou Hospital, Sam Ratulangi University,
Manado, Indonesia

ABSTRACT
Background: The percentage of knee osteoarthritis incidence in Indonesia is
quite high, 15,5% in men and 12,7% in women. As much as 98% knee
osteoarthritis patients are performed total knee replacement (TKR). Besides the
effectiveness of TKR surgery to overcome the knee osteoarthritis, previous
studies showed that 10% to 34% patients reported unfavourable pain outcomes at
between 3 months and 5 years after TKR surgery. There are no reports in Manado,
Indonesia how the quality of life of patients after undergoing TKR surgery.
Therefore, this research aimed to analyze the degree of knee function and the
quality of life of patients after performed total knee replacement in RSUP Prof Dr.
R.D. Kandou Manado in the period of January-December 2018.

Methods: Before surgery and 3-month post-surgery, the patients (N=32) were
evaluated with Knee Society Score questionnaire. The collected data that
consisted of knee score and knee function score were analyzed with paired t-test
using SPSS 23.

Results: Most of the patients are in elderly category of age, and this disease
showed a higher prevalence in women than in men. Patients showed improvement
in the degree of pain, stability, shape, and knee function (p<0,0001) at 3-month
post-surgery. Moreover, as many as 21,87% of patients still experience pain 3-
month post-surgery, this is thought to be caused by lack of physical activity.

Conclusions: The healing of knee osteoarthritis is not only affected by total knee
replacement surgery, but also by postoperatively physical activity. Both of these
actions can improve the quality of life and restore mobility of patients.

Keywords: osteoarthritis, knee society score, knee function score, knee score
INTRODUCTION

Total knee replacement is a surgical procedure to patient in knee joint pain

and/or in the condition of inability mobilization. This condition is mainly caused

by osteoarthritis and rheumatoid arthritis disease. Osteoarthritis is a joint disease

that caused by loss of cartilage, which is a joint bearing, generally caused by

injury or aging. The cartilage of the patient is damaged and become thinner, and

causes more joint friction. This causes pain, stiffness, and inability to walk. The

percentage of knee osteoarthritis incidence in Indonesia is quiet high, 15,5% in

men and 12,7% in women.1 As much as 98% knee osteoarthritis patients are

performed total knee replacement.2 During a total knee replacement, the end of the

femur bone is removed and replaced with a metal shell. The end of the lower leg

bone (tibia) is also removed and replaced with a metal stem. Those two bones are

connected by plastic as movement damper.3 The annual report of Australia

Orthopaedic Association (AOA) National Joint Replacement Registry in 2013

states that patient that performed total knee replacement increased 2,7% compared

the previous year, and increased over time .4

Besides the effectiveness of total knee replacement to overcome knee joint

injury, there are some risks for the patients after perform the surgery, i.e.

prosthetic dislocation due to infection, blood clots around the operating area, and

prolonged pain.3 One way to reduce pain and prevent postoperative complications

after total knee replacement is physical activity after the surgery. 5 Previous studies

showed that 10% to 34% patients reported unfavourable pain outcomes at

between 3 months and 5 years after TKR surgery. 6 In Manado, Indonesia, there

are no reports how the quality of life of patients after undergoing TKR surgery.
Therefore, this research aimed to analyze the degree of knee function and the

quality of life of patients after performed total knee replacement in RSUP Prof Dr.

R.D. Kandou Manado in period of January–December 2018.

METHODS

The subjects of this research were osteoarthritis patients that were

performed total knee replacement in the period of January–December 2018 in

RSUP Prof. Dr. R.D. Kandou Manado. First of all, knee joint of prospective

patients were observed by radiological examination. After the patients were

diagnosed with osteoarthritis disease, the orthopaedist performed total knee

replacement. The individuals were evaluated with the Knee Society Score (KSS)

questionnaire by evaluator in the pre-surgery and 3-month post-surgery period.

The knee score and knee function score of 80-100 indicated that the knee

condition is very good (excellent), the value of 70-79 showed good condition, the

value of 60-69 indicated a fair condition, and a value below 60 indicated a very

severe condition (poor). Moreover, patients were also categorized based on the

functional disorders related to medical weakness or weakness of other joints in the

body of patients (category score), i.e. category A, B and C. Category A is a patient

with unilateral or bilateral total knee replacement (knee contralateral successfully

operated). Category B is a patient with unilateral total knee replacement (knee

contralateral symptomatic). Category C is a patient who had multiple arthritis.

The collected data before and 3-month after surgery were analyzed with paired t-

test using SPSS 23.

RESULTS AND DISCUSSION

There are 32 patients that are diagnosed with osteoarthritis disease and

performed total knee replacement in the period of January–December 2018 in

RSUP Prof Dr. R.D. Kandou Manado. This research showed that osteoarthritis

disease generally occurred in the elderly population and more common in women

(Table 1 and 2). It is well known that aging is associated with changes in the

articular cartilage, subchondral bone, synovium, meniscus, ligaments/tendons, and

common changes mechanisms in all tissues.7 Osteoarthritis patients in this study

showed a higher prevalence in women than in men. Several studies have revealed

that the high prevalence of osteoarthritis in women correlated with the low

estrogen hormone during menopause.8,9 Estrogen supresses bone resorption,

resulting in slowing down the osteoporosis process. Estrogen deficiency can affect

the osteoclast live longer and are therefore able to resorb more bone. In response

to the increased bone resorption, there is increased bone formation and a high-

turnover state develops which leads to bone loss.10

Table 1. Age distribution of patients that perform total knee replacement

Category of ages Number of patients Percentage (%)
(years old)
Middle age (45-59) 7 21,87
Elderly (60) 25 78,13

Table 2. Sex distribution of patients that perform total knee replacement

Sexes Number of patients Percentage (%)
Women 25 78,13
Men 7 21,87

Knee score and knee function score of osteoarthritis patients before

performed total knee replacement are 26,56 and 50,49 (Table 3 and 4). This result
showed that the degree of pain and knee function of patients before surgery are

very severe (poor), i.e. mild to severe knee pain and knee dysfunction that

included walking disorders, disruption of climbing stairs, and the use of walking

aids. Three months postoperative total knee replacement, knee score and knee

function score showed values of 86,36 and 96,25 (Table 3 and 4). Both of these

scores indicated that the degree of pain, stability, shape and knee function of

patients 3-month after surgery are in very good condition (excellent). These

improvement included decreased pain degree, improved flexion range, and

improved antero-posterior and mediolateral plane stability, and improved knee

shape alignment, as well as improvement in walking ability and shape, and the

stability of the knee (p<0,0001; paired t-test), compared to before knee total

replacement surgery (Table 3 and 4). These results were in accordance with

several previous studies. The elderly patients that performed total knee

arthroplasty surgery after 3-month showed improved speed and exercise style

gait11 after 11-month of the surgery showed increased walking speed, increased

flexion range, and improved stability knee shape.12

Table 3. Means, standard deviations (SD), knee score and p-value according
to the period: pre-surgery and 3-month post-surgery
Period N Mean SD Knee score (N)
Poor Fair Good Excellent
Pre-surgery 32 26,56 8,65 32 0 0 0
3-month post-surgery 32 86,38 3,62 0 0 2 30
P-value 1.4661x10-26 ; <0,0001 (paired t-test)

Table 4. Means, standard deviations (SD), knee function score and p-value
according to the period: pre-surgery and 3-month post-surgery
Period N Mean SD Knee score (N)
Poor Fair Good Excellent
Pre-surgery 32 50,49 9,28 26 2 4 0
3-month post-surgery 32 96,25 8,98 0 2 0 30
P-value 4.8845x10-20 ; <0,0001 (paired t-test)
 Based on that results, as many as 21,87% of patients still experience pain

3-month after total knee replacement (Table 5). This is very reasonable, because

postoperative pain of total knee replacement can occur from the first postoperative

day to 6-month postoperatively. Beyond this, this is thought to be caused by lack

of physical activity. This physical activity serves to reduce side effects after total

knee replacement, including pain, limited motion and oedema. This healing of

knee osteoarthritis is not only affected by total knee replacement, but also by

postoperative physical activity. Both of these actions can improve the quality of

life and restore mobility of patients.

Table 5. Category score of patients that perform total knee replacement

Category Knee score (N) Percentage (%)
A 25 78,13
B 7 21,87
C 0 0

CONCLUSIONS AND SUGGESTIONS

Total knee replacement is a surgical procedure that was proven to be

reliable and feasible for end-state knee osteoarthritis patients in elderly

individuals. This surgery can improve the quality of life of patients by reducing

pain and increasing mobility of patients, 3-month postoperatively. As many as

21,87% of patients still experience pain 3-month after surgery, this is thought to

be caused by a lack of physical activity after the surgery. The healing of knee

osteoarthritis is not only caused by total knee replacement, but also by

postoperative physical activity. Proper postoperatively physical activity can

restore the mobility of patients as usual. Future research should be focused on

comparing different designs of prosthesis pre- and postoperatively in a longer

follow-up delay.

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