Effects of microprocessor-controlled prosthetic knees on self-reported mobility, quality of life, and psychological states in patients with transfemoral amputations

OBJECTIVE

This study aimed to determine the effects of the microprocessor-controlled prosthetic knee (MPK) joint on self-mobility, body perceptions, depression, and quality of life in patients with unilateral transfemoral amputations (TFAs).

METHODS

Thirty consecutive patients (28 males, mean age=38.5 years, age range=22-57) who had previously used non-MPKs and who were approved to use swing and stance phase-control MPKs were included in this 12-week clinical study. Before the MPK use and after the three-month follow-up, prosthetic use and locomotor capabilities were evaluated using the Houghton Scale and the Locomotor Capabilities Index (LCI-5), respectively. Body perception was assessed using the Amputee Body Image Scale (ABIS). The depressive symptoms and quality of life were evaluated using the Beck Depression Inventory (BDI) score and the 36-Item Short- Form Health Survey (SF-36), respectively.

RESULTS

After MPK use, statistically significant ameliorations were observed in all outcome measures. The basic and advanced LCI-5 increased from 26.7±2.2 and 24.8±5.2 to 27.6±1.2 (p=0.007) and 27±2.1 (p=0.004), respectively. Houghton scores improved from 9±1 to 10.3±0.8 (p=0.000). The ABIS and BDI scores decreased from 43.2±10.9 and 5.7±6.6 to 37.1±8.9 (p=0.000) and 3.8±4.5 (p=0.015), respectively. Also, the SF-36 physical function and vitality subscales increased from 71.2±24.0 and 75.5±14.6 to 85.6±16.6 (p=0.001) and 81.7±14.1 (p=0.015), respectively.

CONCLUSION

MPK use provides significant improvements in the locomotor capabilities, quality of life, and activities of daily living to patients with TFAs as well as improves their body image perceptions and depressive symptoms.

LEVEL OF EVIDENCE

Level III, Self controlled study.

Comparison of patient reported outcomes after Triathlon(®) and Kinemax Plus prostheses

INTRODUCTION

The Triathlon(®) (Stryker, Kalamazoo, MI, US) total knee replacement was designed to improve patient function and survivorship. The aim of this study was to determine whether the Triathlon(®) prosthesis produces better patient reported outcomes than a previous design by the same manufacturer, the Kinemax Plus.

METHODS

The outcome of 233 knees of patients with a mean age of 68 years (range: 40-80 years) who received the Kinemax Plus prosthesis were compared with the outcomes of 220 knees of patients with a mean age of 70 years (range: 42-90 years) who received the Triathlon(®) prosthesis. Data were collected via postal questionnaire prior to surgery as well as at 8-12 weeks and at 1 year following surgery. Validated questionnaires were used including the WOMAC(®) (Western Ontario and McMaster Universities) pain and function scales, the Knee injury and Osteoarthritis Outcome Score quality of life scale and the self-administered patient satisfaction scale.

RESULTS

This study found that patients who had the Triathlon(®) prosthesis had significantly better pain relief (p<0.0001), function (p=0.028), knee related quality of life (p<0.0001) and satisfaction (p=0.0003) at three months after surgery than those who received the Kinemax Plus prosthesis. In addition, knee related quality of life (p=0.002) and satisfaction (p=0.021) were significantly higher at one year after surgery in Triathlon(®)

PATIENTS

CONCLUSIONS

The findings suggest that return to function and reduction in pain may occur more quickly in patients with a Triathlon(®) prosthesis than in those with the Kinemax Plus.

Early evaluation of quality of life and clinical parameters after total knee arthroplasty

BACKGROUND

Gonarthrosis is the most frequent indication to perform arthroplasty of the knee joint. The purpose of the study was to examine the effect of selected factors on quality of life evaluation in patients after a knee arthroplasty for gonarthrosis.

MATERIAL AND METHODS

Forty patients aged 40 to 85 years (mean age 71.2 years) who underwent knee arthroplasty were examined. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and Short Form-36 (SF-36) questionnaires were used to assess the quality of life of the patients. The questionnaires were completed by patients twice: 1-3 days before the operation and 6 weeks post-surgery. Age, gender, BMI, preoperative knee joint range of motion and limb axis, the presence of other implants, and the presence of a knee contracture before surgery were analysed.

RESULTS

The analysis demonstrated that sex, age, presence of other implants, axis and a preoperative knee contracture did not significantly influence questionnaire scores. As regards the range of knee flexion, outcomes after the arthroplasty were significantly better in patients with pre-operative ranges below 90 masculine than in patients with pre-operative ranges above 90 masculine. BMI had a significant influence on questionnaire scores.

CONCLUSIONS

The BMI value and range of knee flexion before the arthroplasty significantly influenced the quality of life after knee arthroplasty, whereas gender, age, the presence of an additional endoprosthesis or pre-operative joint deformity did not.

Quality of life after knee arthroplasty. A randomized study of 3 designs in 42 patients, compared after 4 years

We assessed different yardsticks for outcome 4 (3-5) years after surgery in a prospective, randomized study of 42 patients, where 3 designs of cemmentless knee prostheses were used. The prognosis with regard to loosening, previously obtained by radiostereometry after 2 years of follow-up, was utilized. Patients with a prognosis of stable implant fixation (two thirds) were compared with those where loosening was predicted (one third). Hospital for Special Surgery score and Visual Analogue Scales regarding pain at rest, "first step" pain, pain during activity and global function, showed consistent postoperative improvements, but no differences between the design and prognosis groups were found. Radiolucent lines were registered both as yes/no and number of zones. Lines and prognosis were associated, but not lines and design groups. Quality of life assessment by the Nottingham Health Profile questionnaire showed that the poor prognosis group had increased pain and significant disturbances of sleep and emotions, as well as difficulty in enjoying hobbies and holiday activities. No differences were found between the design groups. Altogether, the patients showed profiles comparable to a healthy reference group. We conclude that the Nottingham Health Profile is a sensitive, relevant and simple measure of outcome after knee arthroplasty.

The burden of waiting for hip and knee replacements in Ontario. Ontario Hip and Knee Replacement Project Team

The objectives of this study were to assess the impact of major joint replacements in reducing pain and disability and to describe the burden of pain and disability that could be avoided by ordering the queues with respect to severity of disease. A secondary goal was to compare the uses of a general health status measure, the Short Form Health Survey (SF-36), and a disease-specific measure, the Western Ontario McMaster Osteoarthritis Index (WOMAC), for accomplishing the objectives. The results are based on interviews with 209 patients before and after they had surgery. Only 15.9% of the patients had surgery within 3 months' waiting time, 19.2% waited 4-6 months, 30.7% waited 7-9 months, and the remaining 34.1% waited a year or more. The waiting times were unrelated to the severity of pain or disability reported in the initial interview. Following surgery, there were large reductions in the WOMAC scores for pain, stiffness and difficulty in functioning. The SF-36 showed substantial improvements in relief from pain and in physical functioning, and reductions in role limitation due to physical problems, but not for scores related to mental health. The WOMAC scores were more responsive to the benefits of surgery than the SF-36 scores. Queuing systems keyed on burden of symptoms could reduce the burden of pain and disability suffered by patients awaiting surgery. The improvements from hip and knee replacements suggest that equitable access for these procedures should be a priority in Ontario.

Short-term recovery from hip and knee arthroplasty

There are many studies of long-term recovery from major point arthroplasty, but little is known about the first days and weeks after operation. We measured function, emotional state and life evaluation before arthroplasty and at seven and 50 days after in a consecutive series of 40 hip and 23 knee replacements. Pain was relieved significantly at seven days after hip arthroplasty and even more at 50 days. In knee patients, pain relief was modest and was not apparent until 50 days. Functional ability was much improved by 50 days in hip patients, but hardly changed in knee patients. Positive mood and life satisfaction did not improve in either group. Our findings will help with more accurate information for patients before operation and also in judging the rate of recovery.

Prognostic factors for functional outcome of total knee replacement: a prospective study

BACKGROUND

The objective was to investigate whether baseline physical functioning, medical, psychosocial, or demographic variables predict functional outcome in patients undergoing total knee replacement.

METHODS

A prospective cohort study was performed between December 1991 and August 1993. Consecutive, unilateral tricompartmental total knee replacement patients aged > or = 55 yr with osteoarthritis, who met criteria, were enrolled and evaluated one month before and 3 months after total knee replacement. The primary outcome measure was the Medical Outcome Study 36 Item Short Form Health Survey (known as the SF36) Physical Functioning Scale score. The outcome evaluator was not involved in patient care.

RESULTS

A hierarchical multiple regression analysis was performed to calculate the contribution of baseline variables to TKR outcome. Of the 27% of outcome variance explained by the model, demographic variables accounted for 4%, psychosocial variables (motivation, role functioning-emotional, and social functioning) for 19% (p = .013), medical variables (previous reconstruction, comorbidity, body mass index, bodily pain) for 2%, and baseline physical function for 2%.

CONCLUSIONS

Psychosocial variables are significantly related to total knee replacement functional outcome. Assessment of baseline psychological and social functioning may identify a subset of patients at risk for worse outcome. Specific interventions for these patients should be developed and evaluated as components of patient management prior to and after the procedure.

The lower extremity activity profile: a health status instrument for measuring lower extremity disability

The Lower Extremity Activity Profile (LEAP) is a comprehensive measure of lower extremity function. It measures the client's perception of difficulty and satisfaction with performance in the following areas: self care, mobility, household activities, work, leisure activities, and social activities. The development and initial reliability and validity testing of LEAP was conducted with 32 osteoarthritis clients undergoing total knee replacement. Using a one-group repeated measures design, the LEAP, knee range of motion and self-paced walk measures were administered pre-operatively and 3 months post-operatively. The internal consistency of the LEAP using Cronbach's Alpha was 0.73. All LEAP scores showed significant improvement (p<0.01) between the two administration times demonstrating responsiveness of the measure. Correlations of LEAP with the clinical measures were moderate. LEAP is recommended for use as an outcome measure in similar populations, if used in conjunction with clinical and physical performance measures. Further testing of the LEAP is warranted for use in evaluating outcomes of rehabilitation programs addressing lower extremity musculoskeletal impairment and disability.

Quality of life and functional ability in hip and knee replacements: a prospective study

The impact of hip (THA) and knee arthroplasty (TKA) on patients' health-related quality of life (HRQOL), physical ability and functioning was assessed in a two year follow-up study of 276 hip and 176 knee patients. The eligibility criteria were a diagnosis of primary arthrosis, a primary operation, and total joint arthroplasty. Patients were interviewed by questionnaire prior to the operation and 6, 12 and 24 months after the surgery. Subjective health outcomes were assessed with the Nottingham Health Profile and the 15D, a fifteen dimensional HRQOL measure. Patients' physical ability was assessed using measures of activities of daily living, and of physical mobility. Patient related outcome variations were analyzed by regression models. Major improvements were observed for pain, sleep and physical mobility. On average, in most of the quality of life dimensions the patients attained a similar quality of life as the comparable general population and only 4.7% of hip and 9.7% of knee patients had a worse HRQOL score at all three post-operative measurements than at baseline. Naturally, those with the poorest HRQOL pre-operatively gained most from the operation. High age did not lessen HRQOL gains from THA, but in TKA the oldest patients gained least in terms of 15D scores. Hip, but not knee patients with a long education tended to have greater improvements in quality of life and functional ability.

Indications for total hip and total knee arthroplasties. Results of orthopaedic surveys

A lack of consensus regarding the indications for total hip arthroplasty (THA) and total knee arthroplasty (TKA) has been cited as one reason for the variations in the rates of THA and TKA across the United States. The purposes of this study were to survey orthopaedists in a specific geographic area (New York City) regarding the candidacy of patients with osteoarthritis for THA or TKA and to compare indications for THA between orthopaedists at two academic medical centers, The Hospital for Special Surgery in the United States and McGill University in Canada. Orthopaedists were sent mail surveys asking about indications, factors affecting outcomes, and factors that might modify decisions for surgery. Approximately 45% of orthopaedists who performed THA and TKA in New York City in 1992 completed the surveys. Although there were wide variations among surgeons, most surgeons required at least severe pain daily, rest pain several days per week, transfer pain either several days per week (THA) or daily (TKA), and destruction of most of the joint space on radiograph. Younger age, comorbidity, technical difficulties, and lack of motivation modified the decision against surgery, whereas the desire to be independent and return to work swayed the decision for surgery. Most surgeons rated that patients with severe pain, osteoarthritis, or rheumatoid arthritis would have a high likelihood of an excellent outcome, whereas those with comorbidity and certain technical factors would have only a moderate likelihood of an excellent outcome. In the U.S.-Canadian survey of THA, in which more than 90% of surgeons responded, Canadian surgeons tended to require more frequent pain and use of assistive devices for walking. Although there was a majority of opinion for several indications, there was no clear consensus among surgeons regarding the indications for THA and TKA. Possible explanations for this are that isolated indications are not as important as integrating and weighing several indications and that the patient's desire to proceed with THA or TKA is an important driving force in the decision to operate.

Evaluating a revised self-efficacy scale for preoperative patients

Nurses conduct preoperative teaching to help patients cope with the adversities of surgery. Self-efficacy can predict an individual's behavior in aversive situations (eg, surgery); therefore, assessing patients' self-efficacy is one way perioperative nurses can plan patient care and help patients through the surgical experience. This study expands on the results of a previous evaluation of a preoperative self-efficacy scale. The content and face validity of the revised 15-item scale used in this study were assessed before the instrument was administered to preoperative patients. Evidence supports the validity of the multidimensional instrument. Internal consistency estimates > or = .84 support the subscales' reliability.

Health and quality of life before and after hip or knee arthroplasty

The impact of hip and knee arthroplasty based on the patients' own evaluations of their health, quality of life, and physical ability was assessed using a cross-sectional study design. The eligibility criteria were a diagnosis of primary arthrosis, primary operation, and total joint arthroplasty. Preoperative hip and knee patient groups were compared with similar groups who underwent arthroplasty 2 or 5 years previously. Subjective health outcome was assessed with the Nottingham health profile and a 15-dimensional, health-related quality of life measure. Patients' physical ability was assessed using a measure of activities of daily living. Major improvements were observed for pain, sleep, range of motion, and physical ability. However, after surgery, patients were less healthy than the general population of the same age. The health status of patients operated on 2 or 5 years ago was similar, suggesting that health gains persist for several years.

Measuring the success of treatment in patient terms

Measuring the success of major surgeries such as total hip and total knee replacement is important for both case selection and public policy. Patients, purchasers, and practitioners must choose among clinical scoring systems, health status measures, and patient satisfaction ratings to monitor performance and ensure appropriate use of costly procedures. The present study compares results from the Medical Outcomes Study Short Form 36 (SF-36) Health Status Survey and clinical scoring systems to direct patient ratings of success. Data come from a study of 128 total knee-replacement procedure and 211 total hip replacements. Analyses indicate that for both hip and knee patients, success is related closely to posttreatment physical function and bodily pain. Patient ratings of success also are related to the clinical scores used by physicians. Success is related less to change from pretreatment function for knee patients than for hip patients. Although patient ratings of success are generally consistent with other outcome measures, their relationship to patient expectations, satisfaction, and attributions need to be understood before they can become a useful tool for performance monitoring and case selection.

Improvement after surgery in patients with osteoarthrosis of the knee

To ascertain both physical and psychosocial effects of knee surgery in patients with moderate gonarthrosis, clinical examination of patients has been supplemented with a questionnaire SIP (Sickness Impact Profile) to describe the functional health status. Sixty patients, 35 women and 25 men, mean age 63 years, with moderate medial osteoarthrosis of the knee were included in the study. Sixteen patients had bilateral symptoms of gonarthrosis. Patients considered that their knee ostheoarthrosis had great influence physically as well as psychosocially. All patients graded pain during walking. Thirty-five patients were treated with a medial unicompartmental knee endoprosthesis and 25 patients were treated with a valgus osteotomy. After surgery the mean values for all measured variables were improved. Superior results were found among patients with unilateral disease compared to patients with bilateral disease. No differences in results were found between patients given different surgical treatments. The physical and psychosocial influence of osteoarthrosis of the knee were more pronounced in women. It is concluded that the SIP appears to be a measure with sufficient sensitivity to detect physical and psychosocial changes in patients with moderate osteoarthrosis of the knee.

Effectiveness of knee replacement surgery in arthritis

This study examined the effectiveness of knee replacement surgery in an elderly population suffering from arthritis. Four questionnaires which measured pain, mobility, anxiety, depression and social isolation were completed by the study group before and after surgery to assess changes in physical function, psychological state, social interaction and somatic sensation. A statistically significant difference was found in pain which was reduced from a median score of 3 before the operation to 0 afterwards on an intensity scale of 0-5. Statistically significant improvements were also found in the mobility/dependency scores and in the level of anxiety and depression following the operation. It was concluded that knee replacement is a highly effective treatment for arthritis of the knee, reducing pain, increasing mobility and improving the persons emotional state, thus improving the quality of life of the recipient. The use of separate questionnaires to measure single dimensions of quality of life as opposed to a single health profile is also discussed.

Patient-perceived functional outcomes associated with elective hip and knee arthroplasties

The purpose of this study was to determine the effect elective hip and knee arthroplasties had on functional activities of daily living and if the background variables of age, gender, and surgery location can be used to predict functional outcome after these types of surgeries. Data were collected from 43 subjects, 6 to 35 months after they had elective hip or knee arthroplasties. The subjects responded to a mail survey that defined before surgery and after recovery functioning in relation to 22 activities of daily living representing personal care, housework-yard work, and recreation-social activities. Approximately 65% of the subjects reported no change in their ability to perform the 22 surveyed activities. Psychosocial variables appeared to be significant determinants of function. When the selected background data were compared with surgery results, women performed significantly better than men (p less than .05), but age and surgery location were not significant variables affecting outcome.

Primary total hip or knee replacement: evaluation of patients

Total joint replacement surgery has revolutionized the management of chronic arthritis. Careful patient selection, medical follow-up, patient education, and rehabilitation management produce the best results. The indications, contraindications, and results of total knee and hip replacement are reviewed.