Unhappy patientUnhappy patient Following a Total kneeFollowing a Total knee

SummarySummary

IncidenceIncidence AetiologyAetiology DiagnosisDiagnosis PreventionPrevention

Historically 11%-18% not satisfiedHistorically 11%-18% not satisfiedwith TKRwith TKR

Scott C et al.Scott C et al. Predicting dissatisfaction following total Predicting dissatisfaction following total knee replacement 2010; JBJS 92-B, 9, 1253-1258.knee replacement 2010; JBJS 92-B, 9, 1253-1258.

1 Year: 18.6% not satisfied1 Year: 18.6% not satisfied Patient expectationPatient expectation mental component score, depression and pain in other jointsmental component score, depression and pain in other joints

Bourne et al patient satisfaction after TKR. Bourne et al patient satisfaction after TKR. CORR 2010,468:57-63CORR 2010,468:57-63

Ontario 1703 primary TKR (2001-2005)Ontario 1703 primary TKR (2001-2005) 19% Not Satisfied19% Not Satisfied Main predictor is patient expectationsMain predictor is patient expectations

Painful TKR IntrinsicPainful TKR Intrinsic

InfectionInfection Mal-alignmentMal-alignment WearWear

InstabilityInstability LysisLysis

InstabilityInstability CoronalCoronal saggitalsaggital

LooseningLoosening

Soft-tissue impingement Patellar clunk Fabellar impingement Popliteus tendon

impingement Component overhang

Extensor mechanism problems

Patellar maltracking Extensor mechanism disruption

(patellar fracture, patellar tendon rupture, quadricep tendon rupture)

Undersized patellar button with lateral facet impingement Oversized patellar button with overstuffing of patellofemoral

joint Patella baja + alta

Painful TKR ExtrinsicPainful TKR Extrinsic

Hip pathology Spinal disorders Complex regional pain syndrome Psychological disorder Outcome expectation mismatch

DiagnosisDiagnosis

HistoryHistory Pain from startPain from start

ExaminationExamination XrayXray BloodsBloods CT ScanCT Scan

Nicoll D, Rowley DI. J Bone Joint Surg Br. 2010 Sep;92(9):1238-44Nicoll D, Rowley DI. J Bone Joint Surg Br. 2010 Sep;92(9):1238-44 56% of painful TKR had internal rotation errors56% of painful TKR had internal rotation errors

ArthroscopyArthroscopy

PreventionPrevention

Choose surgeonChoose surgeonInfection, mal-alignment, Infection, mal-alignment,

instability, loosening, mal-rotation instability, loosening, mal-rotation

Choose patientChoose patientChoose prosthesisChoose prosthesis

Infection (21%-38%)Infection (21%-38%)

Mal-alignmentMal-alignment

S Johnstone 2/4/9Done 2005

S Johnst

SJ 7/8/09

E M 30/9/04

Massive posterior slope and varus cut

E.M 15/7/9

5/11/2010

2009 2009 InstabilityInstability

20042004

WearWear

WearWearLysisLysis

WearWear

LooseningLoosening

Extensor mechanismExtensor mechanismPatella trackingPatella tracking

2006

2009

Extensor mechanismExtensor mechanismPatella FracturePatella Fracture

otherother14/8/06 5/2/07 15/01/08

1/4/091/4/09

Choose patientChoose patient

Amin et al. J Bone Joint Surg Br. 2006 Oct;88(10):1321-6Amin et al. J Bone Joint Surg Br. 2006 Oct;88(10):1321-6

A higher rate of A higher rate of complications 32%complications 32%

Patient ExpectationPatient Expectation

Ghandi R et al. J Arthroplasty. 2009 Aug;24(5):716-Ghandi R et al. J Arthroplasty. 2009 Aug;24(5):716-21. Patient expectations predict greater pain relief 21. Patient expectations predict greater pain relief with joint arthroplasty.with joint arthroplasty.

a greater expectation of pain relief with surgery a greater expectation of pain relief with surgery independently predicted greater reported pain relief at 1 independently predicted greater reported pain relief at 1 year of follow-upyear of follow-up

Singh JA, et al. Pessimistic explanatory style: a Singh JA, et al. Pessimistic explanatory style: a psychological risk factor for poor pain and functional psychological risk factor for poor pain and functional outcomes two years after knee replacement. outcomes two years after knee replacement. J Bone J Bone Joint Surg [Br]Joint Surg [Br] 2010;92-B:799–806. 2010;92-B:799–806.

Patient outcome expectation Patient outcome expectation mismatch mismatch