The effect of preoperative symptom severity on functional outcome of total knee replacement—patients with the lowest preoperative scores achieve the lowest marks

doi:10.1016/j.knee.2006.01.006

The Knee

Volume 13, Issue 3, June 2006, Pages 216-219

https://doi.org/10.1016/j.knee.2006.01.006 Get rights and content

Abstract

To determine if the functional outcome of total knee replacement (TKR) was affected by the level of preoperative symptom severity, the association between preoperative Oxford Knee Scores (OKS), and 2 year OKS, American Knee Society clinical and function scores (AKSS) was assessed. Data were prospectively collected on 45 cases who had single joint osteoarthritis and no other comorbidities. We have specifically focused on patients with single knee involvement to remove the effect of multiple joint involvement and comorbidities on the OKS. The mean preoperative OKS was 21.4, postoperative OKS 40.0 and postoperative ROM 117 degrees. The postoperative mean AKSS was 86.7 and mean function score was 85.0. The ‘usual pain’ and ‘limp’ components of the OKS had the greatest rises and the ‘kneel’ component had the least improvement. Rather than all patients achieving uniform results post-TKR, patients with more severe symptoms achieved poorer absolute outcomes. The Spearman correlation coefficient between pre- and postoperative OKS was r = 0.4 (p = 0.006). Although the results suggest that waiting too long before intervention compromises the final outcome, a correlation of 0.4 is not strong enough to necessitate change in current practice.

Introduction

The threshold for offering total knee replacement (TKR) has not been clearly defined. The general perceived principle has been to delay TKR until the symptoms are at a level where the potential benefits outweigh the potential risks to the individual.

We have found using the Oxford Knee Score (OKS) a useful tool to objectively grade symptom severity [1]. Our objective was to determine if the level of preoperative symptom severity affected the functional outcome of TKR. We have specifically focused on patients with single knee involvement to remove the effect of multiple joint involvement and comorbidities on the OKS [2].

Section snippets

Patients and methods

Between June 1998 and November 2001, 207 primary TKRs were performed in 179 patients for OA of the knee. Patients with inflammatory arthropathy or unicompartmental replacement were not included in this series. 45 patients with osteoarthritis affecting only one knee and no other comorbidities both preoperatively and at 2 year review were identified. There were 26 males and 19 females. The mean age was 66.9 years with a range of 41 to 78. The mean Body Mass Index was 26.8 (range 19–34).

The Anatomic

Results

The subgroup of patients with osteoarthritis of only one knee (ABC comorbidity category-A) had a mean preoperative OKS of 21.4, a mean postoperative OKS of 40.0 and a mean postoperative ROM of 117 degrees. The postoperative mean AKSS was 86.7 and mean function score was 85.0. The pre- and postoperative Oxford Knee scores of each patient are shown in Fig. 1.

Although the mean postoperative OKS was 40.0, it was observed that patients with a low preoperative OKS did not consistently achieve a high

Discussion

Severe daily pain, destruction of joint space on radiographs and the absence of relative contraindications to surgery are strong indications favouring replacement arthroplasty [4]. However, when presented with less severe symptoms and failure to respond to other treatments, the decision to offer joint replacement surgery may be difficult. Radiological appearances, age and functional disability are often considered in the decision-making process but do they affect the outcome of TKR?

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Cited by (29)

Are patient-related pre-operative factors influencing return to work after total knee arthroplasty
2019, Knee
Citation Excerpt :
Rapid increase in obesity, a risk factor of osteoarthritis and surgical complications [24,25], further increases the need to identify factors that predict the outcome of knee replacement. Thus far, the majority of studies have examined predictors of the clinical outcome and the risk of complications related to TKA [4,26–30]. In contrast, less is known on the predictors of return to work after knee replacement [11,31].
Osteoarthritis is one of the leading causes of disability in working-age patients. The total number of working-age patients undergoing total-knee arthroplasty (TKA) is continuously increasing. The purpose of this study was to identify predictive factors related to general health, health risk behaviors and socioeconomic status influencing the rate of return to work after a TKA.
Overall there were 151,901 patients included in the Finnish Public Sector (FPS) study. The response rate varied between 65 and 73% during the study period. We used Cox proportional hazard models to examine patient-related predictive factors that may influence the rate of return to work after TKA in a cohort of patients (n = 452; n = 362 female; mean age 56.4 years). Predictive factors were measured on average 3.6 years before the operation.
Of the patients, 87% returned to work within one year after TKA at a mean of 116 calendar days. In multivariate analysis, patients at sick-leave ≤ 30 days during the last year before surgery were 2.2 times (95% confidence interval 1.72–2.92) more likely to return to work compared with those with > 30 days of sick-leave. Compared with patients in manual work, those in higher or lower level non-manual work showed a 2.6-fold (1.95–3.52) and 1.5-fold (1.15–1.92) increased probability of returning to work. Age, sex, health risk behaviors, obesity, physical comorbidities, common mental disorders, and other studied health-related factors were not associated with the rate of return to work.
Non-manual job, good self-rated general health and preoperative sick leave ≤ 30 days are associated with a higher rate of return to work.
Predicting patient reported outcome in total knee arthroplasty using body mass index and limb measurements
2018, Knee
Citation Excerpt :
A patient with a low initial OKS would be likely to have a relatively larger overall increase but would still have a relatively lower 12-month score when compared to a patient with a high initial score. This finding has been previously reported and is likely to be due in part to a ceiling effect observed with OKS [16]. Our findings with regard to the effect of gender have been previously described [17].
Body mass index (BMI) has not been shown to correlate with Patient Reported Outcome Measures (PROMs) following total knee arthroplasty (TKA). We investigated the relationship between weight, BMI, limb morphology, and Oxford Knee Score (OKS). Furthermore, the utility of a novel radiological measurement, the Knee Mass Index (KMI), was investigated.
Data including weight, BMI, gender, preoperative and 12 month OKS were collected from an arthroplasty database that contained 268 patients who underwent TKA. Measurements of soft tissue and bone width were made from the preoperative radiograph and ‘KMI’ was calculated. Pearson correlation and multivariate regression analyses were used to assess the relationship between OKS and the above variables.
The novel measurement, KMI, was not a predictor of the OKS. The BMI was predictive of initial OKS (Odds Ratio (OR) − 0.26 p < 0.001), 12 month OKS (OR − 0.39 p < 0.001) and change in OKS (OR − 0.39 p < 0.001). The initial OKS was predictive of 12 month OKS (OR 0.32 p < 0.001) and change in OKS (OR − 0.68 p < 0.001).
The novel KMI metric was not useful in predicting function. Both the post-operative OKS and change in OKS are predicted by BMI and pre-operative OKS. This is one of the first studies to show a relationship between BMI and OKS.
Inferior outcomes of total knee replacement in early radiological stages of osteoarthritis
2014, Knee
Citation Excerpt :
In addition, these patients are more likely to need revision surgery later in life [15]. However, if surgery is performed when the disease is severe then not only may it be more technically difficult but the final gains to be made in pain and function may be less [16–21]. A decision must be reached between the surgeon and the patient as to when the risks of surgery are outweighed by the potential benefits.
Total knee replacement (TKR) for osteoarthritis (OA) is a common and successful operation; the severity of radiographic changes plays a key role as to when it should be performed. This study investigates whether an early radiological grade of OA has an adverse effect on the outcome of TKR in patients with arthroscopically confirmed OA.
Between January 2006 and January 2011 data was collected prospectively on all patients undergoing a primary TKR for OA. We included all patients with a Kellgren–Lawrence score of two or less on their pre-operative radiograph who had had an arthroscopy to confirm significant OA. Our primary outcomes were the Oxford Knee Score (OKS) and a satisfaction rating.
Over the study period 1708 primary TKRs were performed in 1381 patients. We identified 44 TKRs in 43 patients with a Kellgren–Lawrence score of two or less on their pre-operative radiograph. In this group the mean age was 63 years, 66% were female and the mean BMI was 31.7 kg/m². At a mean follow-up of 37 months the mean OKS was only 30 points compared to 36 in all TKRs performed over the same period (p = 0.0004). Only 68% were either satisfied or very satisfied. Eight knees (18%) underwent further surgery, three (6.8%) of which were revision procedures, compared to a revision rate of 1.6% in all patients.
The outcomes of TKR in patients with early radiological changes of OA are inferior to those with significant radiological changes and should be performed with caution.
Level IV case-series.
Predictors and outcomes of lateral release in total knee arthroplasty: A cohort study of 1859 knees
2012, Knee
Citation Excerpt :
The long term outcomes of AKS Knee Score, Functional Score and Pain were the same for LR and non-LR patients, despite the worse pre-operative scores in the LR group. This contradicts previous work showing that poorer preoperative Knee Scores are associated with worse post-operative outcomes [18]. The only statistically significant difference between the two groups was the reduced range of maximal active flexion and loss of active extension in the LR group.
The use of lateral retinacular release (LR) to improve patellar tracking during total knee arthroplasty (TKR) remains contentious. This cohort study explored which pre-operative factors predicted LR, and analysed the effect of LR on short term complications and long term outcomes. One thousand eight hundred fifty-nine TKR patients were followed up for a mean of 5.49 years. One hundred fifty-four (8.3%) underwent LR. After regression analysis only, valgus deformity, year of surgery, maximal flexion and the operative surgeon predicted LR. LR patients stayed longer in hospital (10.8 vs 8.6 days) and had higher transfusion rates (20.3% vs 10.1%) than non-LR patients, but patellar fracture and infection rates were the same. Range of motion was poorer in the LR patients, but AKS Knee and functional scores were unaffected long term.
The Clinical Effect of Gender on Outcome of Total Knee Arthroplasty
2008, Journal of Arthroplasty
Citation Excerpt :
There was no statistical effect on survival of the 3 femoral sizes as it relates to women vs men (P = .6397), female femoral sizes (P = .9287), or male femoral sizes (P = .7743). Most TKAs are performed in women [1,11,12] as demonstrated in this study, in which 59.5% of the TKAs were performed in women. The ratio between the anterior-posterior and medial-lateral dimensions of the distal femur as measured from its distal portion is often different between men and women [2,3,5-7].
The purpose of this study was to quantify the effect of sex on the clinical outcome and survivorship of a total knee arthroplasty (TKA) with clinical and radiographic follow-up. Seven thousand three hundred twenty-six primary AGC (Biomet, Warsaw, Ind) cruciate-retaining TKAs were performed from 1987 to 2004. Of these, 59.5% were performed on women. We examined preoperative and postoperative Knee Society knee score, function scores, pain scores, walking ability, stair-climbing ability, flexion, and implant survivorship based on sex. Female sex was associated with lower overall preoperative clinical scores for all parameters (P < .01). Improvement in Knee Society knee score and flexion was greater for women (P = .006), and there were equal pain relief and walking improvements for both sexes (P < .32). Stair and function score improvements were greater for men (P = .002). Implant survival was 98% for women and men at 15 years (P = .4684). We conclude that improvement after TKA is similar for men and women, with few clinically significant differences. Sex-specific implants would appear to offer no clinical advantage.
Preoperative predictors of returning to work following primary total knee arthroplasty
2011, Journal of Bone and Joint Surgery
There is little in the literature to guide clinicians in advising patients regarding their return to work following a primary total knee arthroplasty. In this study, we aimed to identify which factors are important in estimating a patient's time to return to work following primary total knee arthroplasty, how long patients can anticipate being off from work, and the types of jobs to which patients are able to return following primary total knee arthroplasty.
A prospective cohort study was performed in which patients scheduled for a primary total knee arthroplasty completed a validated questionnaire preoperatively and at four to six weeks, three months, and six months postoperatively. The questionnaire assessed the patient's occupational physical demands, ability to perform job responsibilities, physical status, and motivation to return to work as well as factors that may impact his or her recovery and other workplace characteristics. Two survival analysis models were constructed to evaluate the time to return to work either at least part-time or full-time. Acceleration factors were calculated to indicate the relative percentage of time until the patient returned to work.
The median time to return to work was 8.9 weeks. Patients who reported a sense of urgency about returning to work were found to return in half the time taken by other employees (acceleration factor = 0.468; p < 0.001). Other preoperative factors associated with a faster return to work included being female (acceleration factor = 0.783), self-employment (acceleration factor = 0.792), higher mental health scores (acceleration factor = 0.891), higher physical function scores (acceleration factor = 0.809), higher Functional Comorbidity Index scores (acceleration factor = 0.914), and a handicap accessible workplace (acceleration factor = 0.736). A slower return to work was associated with having less pain preoperatively (acceleration factor = 1.132), having a more physically demanding job (acceleration factor = 1.116), and receiving Workers’ Compensation (acceleration factor = 4.360).
Although the physical demands of a patient's job have a moderate influence on the patient's ability to return to work following a primary total knee arthroplasty, the patient's characteristics, particularly motivation, play a more important role.
Prognostic Level I. See Instructions to Authors for a complete description of levels of evidence.

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The effect of preoperative symptom severity on functional outcome of total knee replacement—patients with the lowest preoperative scores achieve the lowest marks

Abstract

Introduction

Section snippets

Patients and methods

Results

Discussion

J Arthroplasty

J Arthroplasty

J Arthroplasty

The Knee

Questionnaire on the perceptions of patients about total knee replacement

J Bone Joint Surg Br

Specificity of the oxford knee status questionnaire. The effect of disease of the hip or lumbar spine on patients' perception of knee disability

J Bone Joint Surg Br