Patient satisfaction is an important measure of patient-centered outcomes and physician performance. Given the continued growth of the population undergoing surgical intervention for osteoarthritis (OA), and the concomitant growth in the associated direct costs, understanding what factors drive satisfaction in this population is critical. A potentially important driver not previously considered is satisfaction with pre-surgical consultation. We investigated the influence of pre-surgical consultation satisfaction on overall satisfaction following surgery for OA.

Study data are from 1263 patients who underwent surgery for hip (n=480), knee (n=597), and spine (n=186) OA at a large teaching hospital in Toronto, Canada. Before surgery, patient-reported satisfaction with information received and degree of input in decision-making during the pre-surgical consultation was assessed, along with expectations of surgery (regarding pain, activity limitation, expected time to full recovery and likelihood of complete success). Pre- and post-surgery (6 weeks, and 3, 6, and 12 months) patients reported their average pain level in the past week (0–10, 10 is worst). At each follow-up time-point, two pain variables were defined, pain improvement (minimal clinically important difference from baseline ≥2 points) and ‘acceptable’ pain (pain score ≤ 3). Patients also completed a question on satisfaction with the results of the surgery (very dissatisfied/dissatisfied/somewhat satisfied/very satisfied) at each follow-up time point. We used multilevel ordinal logistic regression to examine the influence of pre-surgery satisfaction with consultation on the trajectory of satisfaction over the year of recovery controlling for expectations of surgery, pain improvement, acceptable pain, socio-demographic factors (age, sex, and education), body mass index, comorbidity, and depressive symptoms (Hospital Anxiety and Depression Scale).

Mean age of the sample was 65.5 years, and over half (54.3%) were women. Overall, 74% and 78.9% of patients were satisfied with the information received and with the decision-making in the pre-surgical consultation, respectively, no significant differences were found by surgical joint (p=0.22). Post-surgery, levels of satisfaction varied very little over time (6 weeks: 92.5% were satisfied and 66.4% were very satisfied, 1 year: 91.1% were satisfied and 65.6% were very satisfied). Results from a model including time, surgical joint, satisfaction with consultation and control factors indicated that being satisfied with the information received in the pre-surgical consultation was associated with higher odds of being more satisfied after surgery (OR: 1.2, 95% CI: 1–1.4). Additionally, spine and knee patients were more likely to be dissatisfied than hip patients (OR: 3.2, 95% CI: 2.1–4.9 and OR: 2.5, 95% CI: 1.8–3.4 for spine and knee patients respectively). Achieving pain improvement (OR: 1.7, 95% CI: 1.3–2.4) and acceptable pain (OR: 2.5, 95% CI: 1.6–3.9) were both significantly associated with greater satisfaction. Pre-operative expectations were not significantly associated with post-surgery satisfaction.

Findings highlight the important role of pre-surgery physician-patient communication and information on post-surgery satisfaction. This points to the need to ensure organizational provisions that foster supportive and interactive relationships between surgeons and their patients to improve patients' satisfaction. Findings also highlight that early post-recovery period (i.e. <= 3 months) as a key driver of longer-term satisfaction.

Purpose

With the advent of newer diagnostic imaging tools, the reported prevalence of acute pulmonary embolism (PE) following total hip (THA) and total knee (TKA) arthroplasty appears to be increasing. However, the true prevalence and clinical relevance of these events are unclear. Our study was designed to evaluate the results of routine multi-detector computed tomography (MDCT) in this patient population in the early postoperative period.

Purpose

Total knee arthroplasty (TKA) is the preferred treatment for those with end stage osteoarthritis (OA) and severe functional limitations. With the demographic transition in society, TKA is being offered to a younger patient population. Younger patients are generally more active requiring an increased range of motion, and place greater physiological demands on the prosthesis than typical older patients. The mobile bearing (MB) total knee prosthesis has theoretically been designed to meet these demands. We conducted a meta-analysis and systematic review of randomized controlled trials comparing outcomes of MB and fixed bearing (FB) TKA.

Purpose: Minimally invasive surgery (MIS) knee replacement surgery has experienced a recent surge in popularity, driven by the patient concerns of a faster recovery time and a shorter, more cosmetic scar. However the evaluation of any new medical therapy must include a detailed evaluation of both efficacy and safety outcomes. The primary objective of our meta-analysis was to compare the incidence of complications between minimally invasive(MIS) and standard total knee replacement (TKR) approaches.

Method: We reviewed randomized controlled trials comparing minimally invasive TKR to standard TKR. After testing for publication bias and heterogeneity, the data were aggregated by random-effects modeling. Our primary outcome was the number of complications. Our secondary outcomes were alignment outliers, Knee Society Function Scores, and Knee Society Knee Scores.

Results: We had a total of 9 studies evaluating our primary outcome. Average follow up time ranged from 3 to 28 months. There was no significant publication bias in our study.

The combined odds ratios for complications for the MIS group and alignment outliers were 1.58 (95% CI: 1.01 to 2.47) p< 0.05 and 0.79 (95% CI: 0.34 to 1.82) p=0.58 respectively. The standard difference in means for Knee Society scores was no different between groups.

Conclusion: The results of this meta-analysis demonstrate a statistically significant increase in complication rates with MIS TKR when compared to standard TKR. There were no significant differences in postoperative alignment or KSS at 3 months between the two groups. MIS knee surgery should be approached with caution.

Purpose: Factors influencing patient willingness to undergo elective surgery are poorly understood.

Method: We prospectively evaluated patient concerns prior to surgical consultation for elective spinal, hip, knee, shoulder/elbow (S/E), or foot/ankle (F/A) conditions. Patients were surveyed for demographic data, SF 36 quality of life (QOL) scores and asked to report their greatest concern about considering surgery for their condition, as well as their willingness to undergo surgery if it was offered to them by their treating surgeon.

Results: In our prospective cohort of 743 patients, 364 (51%) were male and 293 (39 %) were evaluated for a spine condition, 74 (10 %) hip, 192 (26 %) knee, 69 (9 %) S/E, and 115 (16 %) F/A. Mean QOL scores were similar for patients across specialities. The top three greatest concerns for undergoing elective musculoskeletal surgery were potential complications (20%), effectiveness (15%) and recovery time (15%) of surgery. When categorized by specialty, concern of surgical complications was the most prevalent in spine (23%) and F/A patients (30%). However, patients were most commonly unsure of risks associated with their respective subspecialty surgery (spine – 56%; hip – 53%; knee – 44%; S/E – 48% and F/A – 33%). The majority of hip patients (89%) perceived a high success rate for hip surgery, while 65% of spine patients where unsure of the success of spine surgery. Patient willingness to undergo surgery was greatest for hip (84%), knee (78%), and S/E (82%) surgery and least for spine (68%) and F/A surgery (74%).

Conclusion: Although patient willingness to consider surgery is clearly a multifactorial decision, patient perception of surgical risk or success prior to surgical consultation are significant factors.

Purpose: Synovial fluid (SF) leptin has been shown to have an association with cartilage degeneration. Our objective was to examine the relationship between different measures of body habitus and SF leptin levels in an end stage knee osteoarthritis (OA) population.

Method: Sixty consecutive patients with knee OA were surveyed prior to surgery for demographic data. Body habitus was assessed with the body mass index (BMI), waist circumference (WC) and waist-hip ratio (WHR). SF and serum samples were analyzed for leptin and adiponectin using specific ELISA. Non-parametric correlations and linear regression modeling was used to identify the relationship between the measures of body habitus and SF leptin levels.

Results: Females had greater levels of leptin than males in both the serum and SF. Significant correlations were found between SF leptin levels and BMI and WC (R2 0.44 and 0.38 respectively, p< 0.05). Regression modeling showed that female gender and WC were independent predictors of a greater SF leptin level independent of age, BMI, and presence of diabetes.(p< 0.05)

Conclusion: WC may be a more accurate measure of body habitus than BMI in the relationship between the metabolic effects of adipose tissue and OA.

Purpose: Prophylactic use of antibiotic-laden bone cement (ALBC) has been proposed to decrease the incidence of deep infections. We asked if the use of antibiotic laden bone cement decreased the deep infection rate following primary total knee replacement (TKA) as compared to plain bone cement (PBC).

Method: We surveyed 1,625 consecutive patients undergoing cemented, primary knee replacement with either ALBC or PBC. Relevant covariates including age, body mass index (BMI), gender, education, and medical comorbidity were collected. Joint pain and functional status were assessed at baseline and at 1 year follow up with the respective Western Ontario McMaster University Osteoarthritis Index (WOMAC) scores. The incidence of deep infection at 1 year follow up was recorded.

Results: There were 811 (49.9%) patients in the ALBC group and 814(50.1%) in the PBC group. There were no differences in age, gender, BMI, education or comorbidity between groups at baseline (p> 0.05). We found a deep infection rate of 3.1% in the ALBC group and 2.2% in the PBC group (p=0.27). Adjusted analysis showed that ALBC was not predictive of a lower infection rate at 1 year (p=0.84).

Conclusion: ALBC did not reduce the incidence of deep infection following primary TKA at 1 year follow up. Further studies are needed to define any high risk groups for which ALBC might be beneficial.

Purpose: Metabolic syndrome (MS) is defined as central adiposity, elevated fasting glucose, hypertension, and dyslipidemia defined as high triglyceride and low high-density lipoprotein (HDL) cholesterol. MS is associated with a systemic proinflammatory and prothrombotic state. We asked if patients with MS undergoing total knee arthroplasty (TKA) have an increased risk for symptomatic deep vein thrombosis at 3 months follow-up (DVT).

Method: 1,460 consecutive patients were reviewed from our joint registry undergoing primary, unilateral TKA between the years of 1998–2006. Demographic variables of age, gender, comorbidity, and education were retrieved. Metabolic syndrome (MS) was defined as body mass index above 30 kg/m2, diabetes, hypertension, and hypercholesterolemia. Logistic regression was used to examine the relationship of MS on the incidence of DVT.

Results: The overall incidence of symptomatic DVT was 4.4% (65/1460). Patients with MS had an increased incidence of DVT as compared to those without MS(15.5% vs 3.4%). Adjusted analysis showed that MS increased the risk of symptomatic DVT by 3.2(95% CI [1.0,15.4], p=0.04) times compared to those without MS.

Conclusion: Hospital protocols developed for prophylactic anti-coagulation following TKR should give special consideration to patients with MS.

Using meta-analysis we compared the survival and clinical outcomes of cemented and uncemented techniques in primary total knee replacement. We reviewed randomised controlled trials and observational studies comparing cemented and uncemented fixation. Our primary outcome was survival of the implant free of aseptic loosening. Our secondary outcome was joint function as measured by the Knee Society score. We identified 15 studies that met our final eligibility criteria. The combined odds ratio for failure of the implant due to aseptic loosening for the uncemented group was 4.2 (95% confidence interval (CI) 2.7 to 6.5) (p < 0.0001). Subgroup analysis of data only from randomised controlled trials showed no differences between the groups for odds of aseptic loosening (odds ratio 1.9, 95% CI 0.55 to 6.40, p = 0.314). The weighted mean difference for the Knee Society score was 0.005 (95% CI −0.26 to 0.26) (p = 0.972).

There was improved survival of the cemented compared to uncemented implants, with no statistically significant difference in the mean Knee Society score between groups for all pooled data.