Pain, Function, and Dissatisfaction after Total knee Arthroplasty
Abstract: Osteoarthritis (OA) is a progressive degenerative joint disorder, and the prevalence increases with age. In Sweden, about one in 4 people over the age of 45 years has OA in at least one joint. As the population ages and the prevalence of obesity increases, OA is expected to increase even more. The knee joint is one of the most commonly affected joints. Total knee arthroplasty (TKA) is the most common method of major surgical intervention for OA of the knee in Sweden. About 13,000 knee arthroplasty procedures were performed in Sweden in 2015. During the past 4 decades, there have been continuous improvements in prosthesis design, preoperative templating, and surgical technique including navigation, pain management, and infection prophylaxis, but still a relatively large proportion of patients (up to 20%) are not satisfied with the outcome after surgery.All knee arthroplasty procedures in Sweden are reported to the Swedish Knee Arthroplasty Register (SKAR), which started in 1975. The purpose of the SKAR is to monitor early and long-term surgical outcomes and complications, especially revision procedures.Through the SKAR, we identified 114 non revised dissatisfied patients in Skåne County, Sweden, and a matched control group of 113 patients who were very satisfied after TKA. The patients had an average of 10.5 years of follow-up and were matched by age, sex, hospital, and date of surgery. There were similar clinical findings, performance tests, and radiographic findings in both groups. In the dissatisfied group, the proportion of patients with anxiety and/or depression was higher, mean VAS pain score was higher, and mean range of motion (ROM) was less.Local infiltration analgesia is used for early postoperative pain relieve in TKA. To prolong the postoperative analgesic effect, continuous intraarticular analgesia for 48 hours has been used. In a prospective double-blind randomized study, 200 TKA patients were given either ropivacaine or NaCl intraarticularly by pump. There were no significant differences regarding postoperative VAS pain, length of hospital stay, analgesic consumption, or ROM between the groups. There were, however, significantly more superficial and deep surgical wound infections in the ropivacaine group.Patella-related problems are an important reason for pain after TKA. In Sweden, patellar resurfacing in primary TKA has decreased since the 1980s, from more than 70% to about 2,5% today. In a prospective randomized study of 74 patients undergoing TKA, we randomized to either patellar resurfacing or no resurfacing. We found no significant differences between the groups regarding VAS pain, physical performance, patient satisfaction, or KOOS 5 subscale scores. None of the patients were reoperated within 6 years. In a prospective cohort study of 186 TKA patients with 4 years of follow-up, preoperative anxiety/depression was a strong indicator of postoperative dissatisfaction. The risk increment for dissatisfaction was more than 6 fold, twice that in patients who had to undergo further surgical procedures because of deep infection postoperatively.Anxiety/depression is an important reason for dissatisfaction after TKA. Continuous intraarticular analgesia is unnecessary in TKA, and patellar resurfacing does not appear to be beneficial in patients with primary OA.
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