Background
Total knee arthroplasty (TKA) is a common procedure with generally good results. By 2030, the annual number of TKA operations performed in the USA is expected to have reached 3.48 million, an increase of 673% from the figures for 2005 [
1]. The most recent annual report from the Swedish knee arthroplasty register shows a similar trend, with an increase from 70 to 140 TKA procedures per 100,000 inhabitants between 2000 and 2015 [
2]. However, despite advances in design and technique, there are still patients who are not satisfied after this procedure. Previous studies have shown many reasons for dissatisfaction [
3‐
24], for example early- and late postoperative complications, unfulfilled expectations, anxiety and depression. Further, earlier studies have shown a correlation between dissatisfaction and mechanical [
5,
14] and/or psychological factors [
16]. In Sweden, the risk of dissatisfaction after knee arthroplasty is about 8% in the absence of complications [
22,
23].
Patient dissatisfaction contradicts the aim of TKA surgery in improving patient’s quality of life [
10,
25‐
27]. It implies a burden for both patients and health care professionals [
28‐
32]. Most of the previous studies conducted to address the problem of dissatisfaction and to analyse the preventable factors in order to decrease this rate. [
6,
10,
12,
15,
25,
26,
33‐
38]
Orthopaedic surgeons may have different ways of dealing with how patients are informed preoperatively, as well as different opinions about the importance of preoperative information in relation to postoperative outcome. Preoperative information includes a general written and verbal information, patient expectations, information about the 20%-non-satisfaction’s rate and psychiatric history. A previous study showed a discordance between surgeon and patient satisfaction after knee arthroplasty surgery [
39]. Moreover, a qualitative study by Conrades et al. showed a relationship between how the TKA patient was informed preoperatively and how much they trusted the department [
40].
When it comes to reducing the risk for patient dissatisfaction, we know the importance of a qualified preoperative information according to the patient’s needs and selection of the right patient for surgery [
12,
18,
40‐
44], but we do not know the extent of the problem in Sweden in terms of the surgeon’s attitude to the information, patient selection, and the surgeon’s opinion about patient dissatisfaction. There are few studies which describe orthopaedic surgeons’ attitudes toward giving information to patients. The aim of this study was therefore to investigate how TKA surgeons in Sweden inform their patients preoperatively, and what kind of information they give. This will lead to strategies and possibly changing protocols to improve the knee surgeon’s attitude in preoperative patient’s information. In turn, it will possibly decrease the dissatisfactions rate in Sweden.
Discussion
The Swedish orthopaedic surgeons in the present study described preoperative patient expectations as an important issue in predicting outcome after TKA surgery. However, this descriptive study revealed deficiencies among many TKA surgeons in supplying preoperative information. The discussion below aims to outline the extent of this problem among knee surgeons in Sweden.
All knee surgeons provided some kind of information to their patients preoperatively. However, only 58% of knee surgeons always provided written information, though 92% always informed their patients verbally. Preoperative information included information about indications, contraindications, surgical procedure, risks and benefits, outcome, and prognosis. Preoperative written and oral information has been shown to reduce postoperative pain and thereby enhance postoperative outcome [
40,
41,
48], and a qualitative study on TKA patients showed that patients who were well informed preoperatively trusted their health care providers [
40]. However, an earlier study showed that preoperative information about anatomy and patho-anatomy had a limited effect on pain management, while information about pain was more effective [
42]. Furthermore, it is of utmost importance that the patients understand the information given. A recent study found that patients with low health literacy had impaired postoperative recovery and lower postoperative quality of life [
49].
Written information in the form of booklets has been shown to have a positive effect on outcome after TKA [
48]. Another study pointed out the importance of providing both verbal and written information together in order to facilitate postoperative pain control [
41]. Consequently, the preoperative provision of written information to all TKA patients could offer a way to increase the satisfaction rate.
In terms of asking about patients’ expectations, only 44% of the surgeons always discussed this important issue with their patients. An earlier study showed that TKA surgery failed to meet the patients’ expectations when it came to kneeling, squatting, and stair climbing, and in particular that the fulfilment of expectations was highly correlated with satisfaction [
43]. Tilbury et al. came to a similar conclusion, emphasizing the importance of preoperative information and education due to the substantial number of TKA patients with unfulfilled expectations [
44]. It is very important for the surgeon to ask about the patient’s expectations, and make it clear to them which activities might be difficult to perform after the surgery. A study revealed that only young, strong patients who did not have a problem with ascending or descending stairs preoperatively were likely to be able to use stairs postoperatively without a problem [
32]. Expectations of improvement in this functional ability may thus contribute to patients’ feeling disappointed after surgery, and so impelling knee surgeons to ask their patients about expectations may decrease the rate of dissatisfaction due to unfulfilled expectations. Patient’s expectations on the outcome of the TKA are not only based on the information given by the knee surgeons, but rather from discussions with other people like friends, family and from information in media [
50].
It is not known whether information about dissatisfaction rate affects outcome after TKA. Earlier research revealed that up to 20% of TKA patients were disappointed with their results [
3,
4,
19,
22] .We therefore suggest that informing patients about the dissatisfaction rate before surgery is of importance, as it could increase their awareness of the expected success rate. Further research is needed to create an individualized risk prediction’s tool.
Only 42% of surgeons in our study always discussed the success rate after TKA surgery, and 10% never discussed this with their patients. Previous studies have shown that the severity of osteoarthritis correlates with satisfaction rate. Schnurr et al. found that patients suffering from mild or moderate osteoarthritis were at risk of dissatisfaction after TKA, and recommended that patients should be told about this [
45]. Another study showed a similarly high dissatisfaction rate among people with mild osteoarthritis changes, and also revealed a high prevalence of chronic non-orthopaedic conditions among these patients, including anxiety/depression, fibromyalgia, low back pain, and prior brain injury [
13].
Our Swedish data showed a high percentage (31%; 68/219) of knee surgeons who sometimes, often or always operated on painful knees with mild radiological osteoarthritis in patients with anxiety/depression. Previous medical history is fundamental in preoperative evaluation. Nonetheless, medical and psychiatric illnesses are equally important, and should always be included in preoperative judgment. In recent years, there has been more recognition of the impact of psychological factors on joint prosthesis outcome. Many studies show a negative relationship between depression/anxiety and prosthesis outcome [
3,
4,
6,
9,
12,
13,
16,
17]. However, only 20% of the surgeons in our study always took a psychiatric history, and 10% never or rarely enquired about psychiatric problems. Earlier research has shown that the rate of depression is 10–13% among the arthroplasty population, and that depression is correlated with an increased risk of poor outcome after surgery [
8,
9]. Thus, awareness of this patient category needs to be increased, at least among Swedish knee surgeons.
Many studies recommend preoperative evaluation and management of psychiatric problems to mitigate postoperative complaints, thereby decreasing dissatisfaction rate after TKA [
3,
8,
11,
15,
17,
18,
24,
51,
52]. In our survey, only 10% of orthopaedic surgeons always consulted a psychiatrist when they suspected a psychiatric problem, and 16% never or rarely did this. Moreover, only 3% of the surgeons used preoperative psychiatric questionnaires. With the support of the above-mentioned literature, the use of this kind of questionnaire can detect patients with a psychiatric disorder. There are no systematic protocols yet in Sweden to refer patients with psychiatric diseases for a professional psychiatric evaluation before TKA surgery. We recommend to build up such systems which we consider as important as referral for physical evaluation before surgery.
The knee surgeon’s responses were consistent with literature considering their believes about the causes of dissatisfaction. This was regarded patients’ expectations [
12,
20,
32,
43,
44,
53], the choice of patient to operate on [
3,
7,
13,
15,
18,
45,
52,
54‐
56], surgery related factors [
21,
57,
58], combination of factors [
10] and poor provision of information [
12,
40,
44,
48,
59].
One limitation of this study is its descriptive design; However, the study does reveal the extent of the knee surgeons who do not provide a sufficient preoperative patient information in Sweden, which may be similar in other countries. Descriptive studies are ranked low in the hierarchy of evidence [
60], but the strength of this survey is that it is unique in describing for the first time Swedish knee surgeons’ attitude to preoperative information. In addition, the qualitative analysis of surgeons’ beliefs shows how surgeons think about dissatisfaction after TKA patients in Sweden. Another weakness is the absence of psychometric analysis of the questionnaire. The questionnaire was constructed by the researchers with the aim of investigating the attitudes of knee surgeons, as there was no validated questionnaire which could answer the aim of the study. Many differences between the groups were statistically non-significant because of multi-categorical comparison between the groups. When we condensed these categories, the differences became statistically significant, however without clinical importance. The high response rate added more strength to this study.
Another limitation of the study is that it only evaluated frequency of information provision, which does not tell us anything about the quality of this information, which may also be important and influence patients’ expectations and satisfaction [
35,
40‐
42,
48,
59,
61]. Moreover, the surgeon’s believes and attitude that showed by the study may not represent the actual daily behavior of knee surgeons.
Acknowledgements
We wish to thank Ole Brus Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden) for statistical advice and help with the SPSS software package. We are also grateful to all the surgeons who answered the study questionnaire.