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The Fate of Patients Not Returning

for Follow-up Five Years After
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Total Knee Arthroplasty

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BY PAUL J. KING, MD, ANDREW S. MALIN, BS, RICHARD D. SCOTT, MD, AND THOMAS S. THORNHILL, MD
Investigation performed at Brigham and Women’s Hospital and New England Baptist Hospital, Boston, Massachusetts

Background: Patients who do not return for follow-up after total knee arthroplasty are often assumed to have had a
worse outcome. We postulated that the Internet may be useful for locating patients who do not return for follow-up.
The purpose of this study was to compare outcomes between patients who attended prescribed postoperative ap-
pointments and those who did not.
Methods: We retrospectively reviewed the outcomes for 161 patients (200 knees) at a minimum of five years after a
total knee replacement. All patients who had had no contact of any type with their surgeon in any manner beyond six
months following the date of the surgery were classified as not having returned for follow-up. When patients could not
be located with use of all available information in their chart, a standardized Internet search algorithm was employed
with use of readily available and free search engines.
Results: Thirty patients with thirty-five treated knees met the definition of not returning for follow-up. Thirteen pa-
tients could not be located with use of the contact information given at their last visit. All were located with use of the
Internet. None of the patients had had knee surgery elsewhere. The reasons for not adhering to the prescribed post-
operative regimen were identified. The group had improved Knee Society pain and function scores compared with the
preoperative values, and the patients were not significantly different from those who did return for follow-up.
Conclusions: The patients who did not attend follow-up appointments in this series had not had any additional sur-
gery and did not have any significant differences in measured outcome variables when compared with patients who
had complied with a follow-up protocol. The Internet proved to be a valuable tool for locating patients who had not re-
turned for follow-up postoperatively.

P
atients who have total knee replacement are advised to
have annual or biannual follow-up evaluations with ra-
diographs. Follow-up is important because early identi-
fication of problems, such as polyethylene wear, can be
addressed early and hopefully can obviate the need for more
extensive surgery. Follow-up is also important for outcome
studies. Debate is ongoing regarding the statistical processing
of patients who are lost to follow-up1-13. Some have argued that
patients who are lost to follow-up may be more likely to have a
worse outcome and to have had surgical intervention else-
where7-9,13. If this is the case, patients lost to follow-up should
be considered as having had a failure in the statistical analyses
of outcome studies. However, the assumption that patients
who were lost to follow-up had a poor outcome may incor-
rectly bias such studies in a negative fashion.
Using patient records and Internet search techniques,
A commentary is available with the electronic versions of this article,
on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our
subscription department, at 781-449-9780, to order the CD-ROM).
we attempted to locate all patients, in a consecutive series of
individuals treated with total knee replacement by one surgeon,
who met our definition of not having returned for follow-up.
We then compared the functional outcomes of those patients
with the outcomes of patients who did return for follow-up.
Our hypothesis was that patients who did not attend pre-
scribed follow-up appointments were not more likely to have
undergone revision surgery or to have a worse outcome com-
pared with patients who did attend follow-up appointments.
Furthermore, we hypothesized that Internet search techniques
would be a useful tool for locating patients who had not re-
turned for follow-up appointments.
Materials and Methods
fter approval by the institutional review board, we retro-
A spectively reviewed the records of 161 patients with a
total of 200 consecutive total knee replacements performed
between April 1996 and July 1997 by the same surgeon
(R.D.S.) with the same prosthesis (PFC Sigma; DePuy, War-
saw, Indiana).
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VO L U M E 86-A · N U M B E R 5 · M AY 2004 F IVE YE A R S A F T E R TO T A L K N E E A R T H RO P L A S T Y
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Fig. 1
Internet search algorithm.

The minimum duration of follow-up was five years Patients who had not returned for follow-up were evalu-
(mean, 64.0 months; range, sixty to seventy-three months). ated by one of the authors (A.S.M.), who had not been in-
All of the operations were performed at one of two hospitals, volved in their care. The evaluation was carried out by means
and all follow-up examinations were conducted at the same
office. For the purposes of this study, we defined patients as
TABLE I Internet Search Engines Utilized
not having returned for follow-up if they had had no contact
of any type with their surgeon beyond six months after the Type Web Address
date of the surgery. Social Security Death Index Ancestry.com
An attempt was made to locate patients who had not re- Telephone directory Anywho.com
turned for follow-up at a minimum of five years by using their
Telephone directory Superpages.com
last known contact information or the last known information
on their next of kin. When a patient could not be located with Telephone directory Switchboard.com
use of this information, a series of searches of free, readily avail- Telephone directory People.yahoo.com
able Internet databases was carried out with use of the patient’s Telephone directory Whitepages.com
most recent demographic information as a starting point (Table
Telephone directory Whowhere.com
I). A standardized algorithm was used for all patients (Fig. 1)14.
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of a telephone interview, during which the patients were asked
about the status of the knee prosthesis, the reason that they
did not return for follow-up, and whether a different surgeon
had been evaluating or treating the knee. A patient who gave
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more than one reason for not adhering to the recommended
follow-up regimen was asked to identify which reason he or
she considered to be primary. Scores for the pain and function
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components of the Knee Society Clinical Rating System were
determined on the basis of this telephone interview and were
compared with the preoperative values recorded in the pa-
tient’s chart15. Patients were educated about the importance of
the recommended follow-up regimen. All patients were asked
to schedule an appointment for complete physical examina-
tion and radiographs.
Patients who had been returning for follow-up appoint-
ments were evaluated in the same fashion. If the patient had
already returned for a follow-up appointment at a minimum
of five years, the Knee Society pain and function scores were
determined from the chart. If the patient had been keeping
follow-up appointments but had not yet returned for the five-
year evaluation, he or she was contacted by one of the authors
(A.S.M.), who administered the pain and function components
of the Knee Society Clinical Rating System in a telephone
interview. The scores were compared with the preoperative
values recorded in the chart. All patients who had not yet re-
turned for a clinical evaluation at a minimum of five years
were asked to return for clinical and radiograph examination.
When a patient had been keeping the prescribed follow-up ap-
pointments but had not yet returned for the five-year follow-
up evaluation and could not be contacted with use of the last
known contact information in the chart, an attempt was made
to locate that patient with use of the standardized Internet
search algorithm employed for the patients who had not re-
turned for follow-up.
Six knees in six patients who had returned for follow-up
at a minimum of five years had required additional surgery.
The Knee Society scores for these six knees were excluded
from the analysis.
Statistical analysis was performed with use of the Stu-
dent t test and the Pearson chi-square test as appropriate, and
significance was considered to be a p value of <0.05. Power
calculations indicated that a sample size of twenty-three pa-
tients designated as not returning for follow-up provided 90%
power for determining differences in mean age, weight, and
preoperative and postoperative pain and function scores be-
tween the two groups with use of the unpaired two-tailed Stu-
dent t test. Power calculations were performed with use of
nQuery Advisor (version 4; Statistical Solutions, Boston, Mas-
sachusetts) (α = 0.05, β = 0.10, effect size = 1.0).
Results
hirty patients with thirty-five replaced knees met the defi-
T nition of not having returned for follow-up. Their mean
age at the time of the surgery was 71.3 years (range, forty-four
to eighty-three years), and their mean weight was 82.0 kg
(range, 52 to 111 kg). Nine (30%) of the patients were male.
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F IVE YE A R S A F T E R TO T A L K N E E A R T H RO P L A S T Y
The preoperative diagnoses included osteoarthritis (twenty-
seven patients), rheumatoid arthritis (one), osteonecrosis
(one), and osteoarthritis secondary to septic arthritis (one).
Preoperatively, twenty-two knees had a varus deformity and
thirteen had a valgus deformity. Seven patients (eight knees)
had died of unrelated causes, at a mean of 32.4 months (range,
eight to fifty-four months) after the total knee replacement,
leaving twenty-three patients with twenty-seven knees avail-
able for follow-up. All twenty-three patients were located, and
all knees were evaluated at a minimum of five years (mean,
63.9 months; range, sixty to sixty-nine months).
One hundred and thirty-one patients with 165 treated
knees who did return for follow-up had a mean age at the time
of surgery of 68.1 years (range, forty to eighty-four years) and
a mean weight of 79.0 kg (range, 30 to 130 kg). Forty-five
(34%) were male. The preoperative diagnoses included osteo-
arthritis (111 patients), rheumatoid arthritis (twelve), osteo-
necrosis (one), posttraumatic osteoarthritis (four), psoriatic
arthritis (two), and spondyloepiphyseal dysplasia (one). Preop-
eratively, 121 knees had a varus deformity and forty-four had
a valgus deformity. Ten patients with eleven treated knees had
died of unrelated causes, at a mean of 42.4 months (range,
twenty-two to sixty-four months) following surgery, leaving
121 patients with 154 knees available for follow-up at a mini-
mum of five years. Two patients (two knees) did not complete
the questionnaire for the Knee Society Clinical Rating System
but did report that they were asymptomatic and had not had
revision surgery at a minimum of five years postoperatively.
One patient (two knees) who had been keeping appointments
could not be located for the evaluation at a minimum of five
years postoperatively.
There was no significant difference between the pa-
tients (knees) who had not attended follow-up evaluations
and those who had with regard to sex, diagnosis, deformity
(varus or valgus), or weight. The patients who had not at-
tended follow-up appointments tended to be older at the time
of the surgery than those who had attended follow-up ap-
pointments (mean age, 71.3 compared with 68.1 years, p =
0.10) and more of them had died (p = 0.01).
Of the thirty patients who had not returned for follow-
up, thirteen (43%) with sixteen replaced knees could not be
located with use of information contained in the chart, but all
were located with a variety of Internet searches performed
with an established search algorithm. Four of these patients
(five knees) had died. The remaining patients were contacted.
Twenty-six (20%) of the 131 patients who had been
keeping their prescribed follow-up appointments had not yet
returned for their follow-up evaluation at a minimum of five
years and could not be located with use of their last known
contact information contained in the chart. Twenty-four of
these patients were located with use of the Internet search al-
gorithm. Eight of them had died.
Overall, thirty-seven (95%) of the thirty-nine patients
who could not be located with use of the last known contact
and demographic information contained in their chart were
found with the Internet search algorithm. One of the two pa-
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TABLE II Reasons Given for Not Returning for Follow-up Appointments
Primary Reason
Not having any problems with knees
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Forgot/did not know follow-up was recommended
Difficult/long trip for follow-up appointment
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Patient died
Too busy/preoccupied with other health issues
Seeing another surgeon for convenience
Unhappy with provided care
Delaying the inevitable replacement of other knee
tients who could not be located subsequently returned for
follow-up without having been contacted.
None of the patients who had not returned for follow-up
had required additional surgery on the knee; six patients who
had returned for a follow-up evaluation at a minimum of five
years had required additional surgery on the knee. This differ-
ence was not significant. The reasons for additional surgery in-
cluded late infection (two patients), arthroscopic manipulation
(two), synovectomy with exchange of the polyethylene liner be-
cause of recurrent varus deformity (one), and excision of a lat-
eral joint line cyst (one).
The reasons that the patients gave for not returning for
follow-up are listed in Table II. Both the patients who had re-
turned for follow-up and those who had not had a significant
improvement in the postoperative scores for the pain and
function components of the Knee Society Clinical Rating Sys-
tem compared with the preoperative values (p < 0.0001).
There was no significant difference in the pain and function
scores at a minimum of five years between the patients who
had and those who had not attended follow-up appointments.
Two patients who had not returned for follow-up ap-
pointments and four who had returned reported that they
were dissatisfied with the knee replacement (p = 0.25). Of the
two dissatisfied patients who had not returned for follow-up
appointments, one had bilateral osteoarthritis of the knee and
complained of a limb-length discrepancy following correc-
tion of a large varus deformity in one of the knees. The other
patient complained of residual stiffness one month after the
surgery and did not return for follow-up again.
Discussion
here was no difference between patients who had and those
T who had not attended follow-up appointments in this con-
secutive series of total knee replacements evaluated at a mini-
mum of five years postoperatively. Knee Society scores for pain
and function were similar, and no patient who had not attended
follow-up appointments had required revision surgery.
Loss of patients to follow-up is a common and unavoid-
able problem in outcome studies. Much has been written
about the statistical handling of such patients1-5. The problem
is intensified when long-term follow-up is required, particu-
larly when the prevalence of failure is low, as is the case with
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Secondary Reason Total Responses
1 10 11
8 1 9
5 2 7
7 0 7
4 0 4
3 0 3
2 0 2
0 1 1
total joint replacement. If patients who are not available for
follow-up evaluation are expected to have a worse outcome, as
some have suggested, authors of orthopaedic outcome studies
who do not account for these patients may report results that
are more favorable than should be expected7-9,11,12.
Joshi et al. recently reported on a series of 563 consecu-
tive knee replacements and found no significant difference be-
tween the outcomes of patients who had and had not attended
follow-up visits16. Konig et al. found, in a series of knee re-
placements in Germany, that patients who had not returned
for follow-up tended to be older at the time of surgery and to
have more medical problems at the time of follow-up but
none had required revision surgery10. Dorey and Amstutz re-
ported similar results in a series of patients with total hip
arthroplasty6. Others have refuted these findings but have re-
lied on data from studies investigating neuroses and with pa-
tients with heart disease7. Murray et al. reported on a series of
patients treated with hip replacement and concluded that
those who were lost to follow-up could be expected to have
poorer outcomes9. However, those authors compared data in
a matched control group of patients who had returned for
follow-up with information derived from the last known eval-
uation of those who had not. The current study and the study
by Joshi et al. both involved patients treated by a single sur-
geon, and both we and Joshi et al. actively sought out patients
who had not attended follow-up visits. Of all of the patients in
the two studies, which included 763 total knee replacements,
only one patient with two knee replacements was not located.
These comprehensive follow-up studies, unlike the study by
Murray et al., do not require any assumptions regarding the
outcome of patients who were not located. Although Dorey
and Amstutz used a different methodology in their study on
total hip arthroplasty, their conclusion was the same as ours.
We agree with Laupacis that complete follow-up is cer-
tainly preferable when possible7. Appropriate follow-up may
help to avoid complications associated with a delay in the
diagnosis of wear or loosening of a total knee replacement17.
Unfortunately, in studies of total joint arthroplasty with long
follow-up intervals, locating patients can be difficult, time-
consuming, and cost prohibitive. Joshi et al. used a full-time
research assistant and a private detective in order to obtain
follow-up data on all of the patients in their series16. Our study
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is unique in that “lost” patients were located without substan-
tial difficulty, time expenditure, cost, or utilization of private
detectives or other outside resources. Patients who could not
be located with use of the contact information in their chart
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were found with simple, readily available, and free Internet
search engines and use of a standardized search algorithm. We
therefore proved our second hypothesis that the Internet is a
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useful tool for locating patients. The technique was time effi-
cient and successfully located 95% of the patients who had not
returned for follow-up and who could not be located with use
of the last known contact information.
The wide availability and ease of use of the Internet
make this modality attractive for researchers, and its efficacy
should improve as the search engines become more sophisti-
cated and easier to use. Search engines are easy to use but vary
in their efficacy14. Using an Internet search engine that refer-
enced the Social Security Death Index allowed us to determine
which missing patients had died, and this saved substantial
time and resources by immediately ending additional at-
tempts to locate those patients. The proliferation of informa-
tion on the Internet should continue to make it easier to find
patients. However, important issues regarding patient confi-
dentiality and privacy need to be considered as the use of the
Internet expands in the health-care setting.
On the basis of our results, we believe that patients who
do not attend follow-up appointments in studies of total joint
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F IVE YE A R S A F T E R TO T A L K N E E A R T H RO P L A S T Y
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NOTE: The authors thank David Zurakowski, PhD, for his assistance with the statistical analysis.
Paul J. King, MD
Anne Arundel Orthopaedic Surgeons, 2003 Medical Parkway, Suite 400,
Annapolis, MD 21401. E-mail address: pjking10@msn.com
Andrew S. Malin, BS
Richard D. Scott, MD
Thomas S. Thornhill, MD
Department of Orthopaedic Surgery, Brigham and Women’s Hospital,
75 Francis Street, Boston, MA 02115
The authors did not receive grants or outside funding in support of their
research or preparation of this manuscript. One or more of the authors
received payments or other benefits or a commitment or agreement to
provide such benefits from a commercial entity (DePuy, a Johnson and
Johnson Company). No commercial entity paid or directed, or agreed to
pay or direct, any benefits to any research fund, foundation, educational
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