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Quality of life outcomes in patients undergoing knee replacement surgery: longitudinal findings from the QPro-Gin study

BMC Musculoskeletal Disorders volume 21, Article number: 436 (2020) Cite this article

Abstract

Background

Many patients report postoperative pain, limited improvement in physical function and poor quality of life (QOL) after knee replacement surgery. Our study uses baseline predictors of change to investigate the QOL of patients with knee osteoarthritis 3-months after knee replacement surgery.

Methods

A prospective observational study was designed to evaluate patients (n = 132) scheduled for uni-compartmental or total knee replacement surgery who were assessed at baseline (preoperatively) and 3-months after. Physical and mental endpoints based on the component scores of the SF-12 and on the Western Ontario and McMaster Universities Arthritis (WOMAC) index were used to investigate patients’ QOL. Generalised estimating equation methodology was used to assess patients’ baseline characteristics (age, sex, education, body mass index (BMI), comorbidity, depressive symptoms, cognitive impairment, smoking/alcohol and type of surgery), the study endpoints and their changes over a 3-month post-surgery period. Stratified analyses by rehabilitation status after discharge were performed.

Results

Longitudinal data analysis showed that the baseline factors associated with improvement in general QOL at the 3-month post-surgery assessment were higher BMI, a high comorbidity, total (as opposed to unicompartmental) knee replacement and low education level. Data analysis of the patients who underwent rehabilitation after discharge revealed that the current smokers’ physical QOL worsened over time. The general QOL was unchanged over time in the presence of depressive symptomatology.

Conclusions

These findings underline the importance of using comprehensive assessment methods to identify factors affecting functionality and QOL, and developing interventions to improve the health/wellbeing of patients after knee replacement.

Peer Review reports

Background

The primary pathology requiring knee replacement surgery is knee osteoarthritis (OA). Rising life expectancies and the global obesity epidemic are leading to a rapid increase in the prevalence of knee OA and, therefore, to a greater demand for knee replacement surgery. These patterns are causing and will continue to cause future important implications for health care expenditures [1]. Acute and persistent pain (usually at night), severe functional disability and the failure of non-surgical treatments are the deciding factors for surgical intervention [2]. Two principal surgical options for late-stage medial compartment OA of the knee are total knee arthroplasty (TKA) or unicompartmental knee arthroplasty (UKA), in which only the damaged compartment of the knee is replaced [3, 4]. Surgeons often disagree about the best choice of surgery for these patients, having often identical pathologies, which has caused variations in implants and treatment [5].

Assessments of knee replacement surgery outcomes traditionally use revision of knee joint replacement as an endpoint; however, other physical variables may also be assessed [1]. Although significant advancements have been made in both surgical techniques and prosthesis placement procedures, many patients continue to report postoperative pain, limited improvement in physical function, modest clinical benefit of UKA over TKA and poor quality of life (QOL) [6]. In several studies furthermore, it has been shown that younger age, in which UKA is more indicated, is associated with higher revision rates [7,8,9]. On the other hand, octogenarians and nonagenarians undergoing elective TKA experience relatively high rates of complications, even if most of these are minor. At the same time, ADL-dependent patients and those with a history of congestive heart failure or chronic obstructive pulmonary disease are more likely to experience unplanned readmission [10].

These suboptimal results may not be entirely due to the surgical procedure itself, to surgery-related complications, or to physical comorbidities. The patient’s pre-operative level of pain and psychological profile, or other variables may be involved [11].

The multi-dimensional QOL is a measure that places heavy emphasis on “health”, which is not characterised as the complete absence of disease but as a condition of general physical, social and mental well-being [12]. When that type of approach is used, the success of a knee replacement procedure and the QOL of a patient after surgery must be evaluated not only on the basis of physical function but also on psychological and social factors that could influence the surgery’s outcomes. To our knowledge and despite data underlining the importance of using a multi-dimensional approach, there have been few studies of the outcomes of different types of knee replacement, and findings gathered until now tend to be conflicting [1, 11, 13].

The primary aim of the present analysis was to use physical and mental endpoints to investigate patient QOL at the time of knee replacement surgery and 3-months later. The secondary aim was to identify the baseline predictors of change in QOL in the patients who were stratified according to their participation or non-participation in a rehabilitation program after discharge.

Methods

Study design and sample characteristics

The competent Ethical Committee of Padova approved the Quality of Life in Knee Prostheses (QPro-Gin) project (identifier: 258 OS), which is a single-centre prospective study. The inclusion criteria for this study were the following: age ≥ 40 years; OA or osteonecrosis (one compartment or both for UKA and TKA, respectively); and being scheduled for unicompartmental or total knee replacement surgery at the Orthopaedics and Traumatology Unit of the Abano Terme (Italy) General Hospital. The exclusion criteria included: diagnosis of inflammatory arthritis, haemochromatosis, chondrocalcinosis or haemophilia; multi-compartment disease; unsuccessful correctional osteotomy or ipsilateral UKA; symptomatic knee instability or anterior cruciate ligament deficiency; immobility or other neurological conditions affecting musculoskeletal function.

All subjects participating in this study signed a consent form, which was obtained on the day the baseline data were collected before undergoing surgery. The type of knee replacement surgery was categorised as UKA (the MAKO Stryker, assisted surgery, Fort Lauderdale, USA and the Oxford mobile-bearing knee implant, Zimmer Biomet Ltd. Oxford) versus TKA (the Vanguard prosthesis, Zimmer Biomet, Warsaw, USA).

The indications for surgery were debilitating knee pain, defined as severe persistent pain, causing important reduction of knee functionality during basic activities of daily living (ADLs), in combination with isolated medial unicompartmental OA with grade 3 loss of articular cartilage according to the Kellgren and Lawrence grading scale [14] or spontaneous medial osteonecrosis of the femur with grade 3 loss of articular cartilage or minor subchondral collapse for UKA and primary end-stage diffused symptomatic OA of the knee for TKA, respectively. Standard radiographic evaluation was carried out preoperatively on weight-bearing radiographs: anteroposterior, Rosenberg, lateral and skyline views.

Surgical techniques, post-operative treatment and rehabilitation program

All operative procedures, performed with a tourniquet, were carried out by one of two senior authors, both with over 10 years of experience performing both UKA and TKA. Plexus anaesthesia was performed entailing a regional block, which involved both sciatic and femoral nerves. Sedation was used when necessary. Intravenous Cefazolin was used as perioperative prophylaxis (1 g 4 times/day) and continued for a 24 h period after surgery. Postoperative antithrombotic therapy (Natrium Enoxaparin) was given until full free weight bearing was achieved.

The same standardized post-operative physical rehabilitation protocol, which is still applied routinely by physiotherapist teams, was used for each patient regardless of the type of implants, described as follows. Structured physical therapy was begun the day after surgery and continued during the in-hospital stay for a week in case of UKA, and 2 weeks for TKA. The patients having undergone UKA were instructed to sit up at bedside the evening of their surgery and to begin ambulating with assistance the day after surgery. For patients having undergone TKA, active range of motion (ROM) was encouraged and full weight-bearing ambulation was allowed on post-operative day 2 when quadricep inhibition from the femoral nerve block had ceased. Each physiotherapy session lasted 25 min every day, and all rehabilitation was performed by the same multidisciplinary hospital team. Patients were discharged to their own homes after adequate mobilisation with the use of crutches, and independent ascent and descent of stairs. They were encouraged to do specific knee ROM exercises and to seek formal physical therapy on an outpatient basis two or three times per week for the first 3 months. No patients were discharged to a rehabilitation centre or other skilled nursing facilities.

Patient assessment

There were two time points for data collection: at baseline (during the scheduled hospitalisations prior to the knee-replacement surgery) and 3-months after surgery. Post-surgery, each participant underwent a standard clinical rehabilitation program in place at Abano Terme General Hospital, as described above. According to the inclusion and exclusion criteria, the eligible participants were selected from the surgery list; each patient included in this study was assessed by a board-certified neuropsychologist. The baseline evaluations were carried out through January and May 2013, and the 3-month post-surgery evaluations were carried out from April 2013 to July 2013.

Data collection

Information on the participants’ demographic variables, medical history and medication, lifestyle (smoking and alcohol use) and type of surgery scheduled (UKA or TKA) was collected at baseline. Data on pain, stiffness and disability due to knee OA were collected at baseline and 3 months after surgery. Information on participation in a rehabilitation program after discharge was collected at the 3-month post-surgery assessment.

Measures

Endpoints

The QPro-Gin study’s primary endpoint was health-related QOL as measured by the Short-Form General Health Survey (SF-12) Questionnaire. The patients were asked to fill out the Physical (PCS) and Mental (MCS) components, which are considered QOL indicators [15].

The QPro-Gin study’s secondary endpoint was the self-reported assessment of pain, stiffness and disability in the knee as measured using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) [16], an instrument that evaluates three dimensions (pain, stiffness and physical function).

Information about the sample population

Information was gathered on patient age (categorised as < 65 versus ≥65), sex, and educational level (defined as low education = elementary or middle school versus high education = high school or university degree). The patients’ Body Mass Index (BMI) was categorised as BMI < 30 kg/m2 versus BMI ≥30, the latter defined obesity [17]. Scores of 6 or above on the Short Form Geriatric Depression Scale (GDS) indicated the presence of depressive symptoms [18]. Cognitive impairment was defined as Mini-Mental State Examination (MMSE) score < 24 [19].

Comorbidity was defined as the presence of ≥4 (median value) coexisting disorders of the sensory, respiratory, cardiovascular, gastrointestinal, endocrine/metabolic, neurological, urogenital/gynaecological, immunologic-rheumatic, musculoskeletal, psychiatric systems, or cancer. Medication used (dichotomised as “yes” or “no”) referred to corticosteroid/anti-inflammatory/analgesic drugs and to medicines for cardiovascular, gastrointestinal, metabolic, neurological, bone and other diseases. The lifestyle behaviours that were assessed were smoking status (current versus not current smoking) and alcohol consumption (current user versus non-user).

At the 3-months post-surgery assessment, patients were asked if they had followed the rehabilitation program after discharge (dichotomised as “yes” or “no”).

Statistical analysis

Calculating the sample size

The sample size needed for our analysis was calculated a priori in accordance with Poitras et al.’s study [20]. Because 3 months after joint replacement, the mean PCS of the SF-12 of 61 patients was 38.7 ± 9.5, we calculated that a sample size of 120 was required to ensure a probability of 0.90 to produce a two-sided 95% confidence interval with a distance from the mean to the limit that was less than or equal to 2. A 20% overestimation, 151 patients, were thus enrolled to allow for the possibility of dropouts.

Baseline sample characteristics

Continuous variables were expressed as mean and standard deviation (SD) or as median and interquartile range (IQR) if non-normally distributed; categorical variables were reported as percentages. Comparisons of normally distributed characteristics were carried out using the generalised linear model procedure after homoscedasticity was verified using Levine’s test (in case of heteroscedasticity, Welch’s analysis of variance was applied).

Change over time

The change in the endpoints over the 3-month after surgery period was assessed using the paired t-test.

Generalised estimating equation (GEE) models for longitudinal data analysis were used to assess the influence of baseline characteristics (age, sex, education level, BMI, depressive symptoms, cognitive impairment, number of comorbid diseases, smoking and alcohol statuses, type of surgery) on change over the 3-month post-surgery period [21].

GEE models estimated β-coefficients, 95% confidence intervals (95% CI), and standard error (SE) of the cross-sectional (between-individuals) and longitudinal (within-individual) associations between independent variables and endpoints. Each GEE model also included an interaction term between time and the independent variables.

Predicting models of endpoints stratified by rehabilitation after discharge were developed.

P values of 0.05 for two-tailed tests were considered significant. Statistical analyses were performed using SAS software (SAS Institute Inc., Cary, NC, USA) version 9.4.

Results

One hundred fifty-one patients (41 men = 27.2%; 110 women = 72.8% with a mean age of 68.3 years (SD 8.3) scheduled for knee replacement surgery were considered eligible to participate in the study. Nineteen (12.6%) withdrew from the study after the baseline assessment: 6 freely chose to abandon the study, 12 were lost, and 1 underwent a different type of surgery. Their characteristics were nevertheless similar to those of the 132 (87.4%) who did complete the two assessments upon which the analyses were based. Among them, 47 were treated by UKA (24 MAKO) while 85 by TKA.

Patients’ characteristics at baseline

The baseline characteristics of the participants are presented in Table 1. Most of the patients were female and overweight who underwent a TKA procedure; they had on average ≥ 4 comorbid conditions, in particular musculoskeletal and cardiovascular diseases.

Table 1 Patients’ characteristics at baseline
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Table 2 presents the baseline distribution of SF-12 and WOMAC-index according to patients’ characteristics.

Table 2 Baseline distribution of sf-12 and womac-index according to patients’ characteristics
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SF-12 scores showed that the women had worse scores on both components. The patients with low education tended to have worse MCS scores, and the obese patients tended to have worse PCS scores with respect to those with a BMI < 30 kg/m2. The patients with ≥4 diseases had worse MCS scores. There were no statistically significant differences in the SF-12 scores for age, smoking/alcohol status and type of surgery.

Analysis of the WOMAC-Index scores (mean ± SD 45.7 ± 16.0) showed that the women had significantly worse scores. The patients with low education, depressive symptoms who were not currently alcohol users and undergoing TKA surgery tended to have worse scores. There were no statistically significant differences in the WOMAC-Index scores for age, BMI, cognitive impairment, comorbidity and smoking habits.

Change in endpoints

The mean change (Follow-up value – Baseline value) for the PCS was 4.2 (SD 11.3); it was 2.0 (SD 11.3) for the MCS; it was − 23.2 (SD 17.6) for the WOMAC–Index (Table 3). A statistically significant improvement in all end points over time was detected in the population as a whole.

Table 3 Change in endpoints
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Association of the baseline characteristics with the endpoints

Tables 4, 5 and 6 show the results of the GEE analyses that assessed the influence of the baseline characteristics on each endpoint, stratifying the patients according to rehabilitation after discharge. After discharge, 3 months after surgery, 40 of the patients (30% of the study completers) had continued the same rehabilitation program at home.

Table 4 SF 12-PCS and associated patients’ characteristics and clinical conditions: multivariable generalised estimating equation models
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Table 5 SF 12-MCS and associated patients’ characteristics and clinical conditions: multivariable generalised estimating equation models
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Table 6 WOMAC-Index and associated patients’ characteristics and clinical conditions: multivariable generalised estimating equation models
Full size table

PCS of SF-12

The PCS (Table 4) worsened over time in the older patients, but it improved in the obese patients and in those with 4 and more comorbid diseases. The negative association between depressive symptoms and PCS did not change over time.

When the data of the patients who underwent rehabilitation after discharge were analysed, the PCS worsened over time in the older patients and current smokers; however, it improved in the patients with 4 or more diseases. It was unchanged over time in the patients who underwent TKA and with depressive symptoms.

MCS of SF-12

The MCS (Table 5) improved over time in the patients with low education, but it was unchanged in those with a high degree of comorbidity and depressive symptoms.

When the data of the patients who underwent rehabilitation after discharge were analysed, the MCS was found to improve over time in those with ≥4 diseases and in the current alcohol users; it was unchanged in the presence of depressive symptoms and in the low education (negative associations) and cognitively impaired patients (positive association).

WOMAC-Index

The WOMAC-Index scores (Table 6) improved in a marginally significant manner over time in the obese patients. They were unchanged in the presence of depressive symptoms in the patients who underwent a total knee replacement.

When the data of the patients who underwent rehabilitation after discharge were analysed, it was found that pain, stiffness and disability perception improved in the obese patients but worsened over time in the current smokers.

When the data of the patients who did not undergo rehabilitation after discharge were analysed, it was found that pain, stiffness and disability perception improved in the females, in the obese patients, and in those who underwent a TKA. They worsened instead over time in the patients with low education; they were unchanged in the presence of depressive symptoms.

Discussion

This study aimed to examine the QOL of patients with knee OA, particularly in patients at high risk of functional decline and with relevant comorbidity burdens and high levels of polypharmacotherapy, at the time of and following knee replacement surgery. At baseline, the women had worse general health status, both physical and mental, and reported more pain and made more complaints about OA with respect to men [22].

The patients’ QOL was improved 3-months after surgery according to both the SF-12 and the WOMAC–Index, confirming that knee replacement surgery can determine a substantial improvement in QOL in patients with end-stage OA [1]. Analysis of the relationship between the baseline characteristics and the various endpoints revealed that higher BMI, higher comorbidity and TKA surgery were the variables associated with improvement. The fact that the patients affected by obesity and with ≥4 comorbid conditions showed considerable improvement in physical function and reported less pain is not surprising. Obese patients, who are frequently characterised by difficulty in walking and function, certainly benefit the most from surgery that permits them to increase their physical activity. The same can be said for comorbidities, as individuals affected by the typical physical impairments associated to cardiovascular and other frequent chronic conditions surely benefit from improved lower limb physical function.

Patients with knee OA are characterised by slow walking gait, fatigue and low levels of physical activity. As the main symptom of OA is joint pain, which is exacerbated by exercise and relieved by rest, it strongly affects the individual’s ability to perform the basic ADLs and often leads to frailty and disability [23, 24]. It is known that knee OA and frailty share common risk factors, such as obesity and comorbidities. The finding that patients with knee OA and these additional conditions benefit from knee replacement surgery is important because it demonstrates that knee replacement surgery can contribute to preventing frailty, a highly prevalent condition that leads to an increased risk of disability, falls, hospitalisation and death [25].

An analysis of study data uncovered that depressive symptoms at baseline was associated to higher self-reported pain, stiffness and disability, and this association remained unchanged at the 3-month post-surgery assessment. These findings underline the importance of depressive symptoms and their strong impact on the QOL of OA patients, independent from the type of surgical treatment or participation in a rehabilitation program. A randomised clinical trial evaluating 1801 depressed older patients with OA demonstrated that pharmacological treatment and/or psychotherapy had a significant beneficial effect not only on the depressive symptoms, but also on QOL, physical function and perception of OA-linked pain. Given the high co-prevalence of depressive symptoms in OA elderly patients presumably leading to worse QOL, the hypothesis that monitoring and treating depression could lessen the burden of OA in these patients seems more than reasonable [26].

In the management of knee OA, the efficiency of replacement surgery compared with alternative conservative strategies has been proven [27]. However, debate continues over what the most effective type of prosthesis is for the treatment of symptomatic primary medial compartment OA. Several advantages of UKA over TKA, including preservation of bone stock, faster recovery, lower overall cost, reduced morbidity, better functional outcome because of more normal knee kinematics, and subjective feeling of a more natural knee [28,29,30,31,32,33,34,35]. The main problem as far as UKA is concerned, is the higher revision rate, particularly in younger patients, with respect to TKA [36,37,38,39].

In our study, the type of implant was found to be a predictor of improvement at the 3-month post-surgery assessment. Specifically, TKA was significantly associated to an improvement in QOL. We believe that these results were probably due to a response shift bias, because patients who underwent TKA were experiencing more pain and disability prior to the surgery and thus perceived more improvement in function and pain with respect to their partial-surgery counterparts. OA radiological severity, postoperative complications, preoperative clinical parameters and comorbidities were defined common predictors for 5-year outcomes after knee replacement [27]. Hence, worse preoperative function and radiological severity of OA are generally associated with better postoperative improvement after TKA and greater patient satisfaction. Return to daily activity continues to be a key factor after knee arthroplasty. Patients often have expectation about being able to return to the activities they enjoyed prior to their limitations caused by knee OA.

Among the patients who did not give up the rehabilitation program after discharge, the current smokers reported worse physical function and pain symptoms. Patients are usually encouraged to carry out bending and straightening exercises as well as flexing and relaxing thigh muscles during rehabilitation programs after knee replacement surgery, which can last several months. They are also asked to walk progressively longer distances and to gradually include some resistance training.

The perception of worse physical function, pain and disability at three-months after surgery reported by the smokers might be due to the fact that they have greater ambulatory dysfunction associated in part to their higher CVD and comorbidity rates. Although it has been demonstrated that smokers benefit from rehabilitation programs as much as non-smokers, the benefits are nevertheless usually evident after at least a 6-month period. Despite the fact that exercise effectively seems to improve functional independence in both smoking and non-smoking patients, the former may report worse physical function and more pain over only a 3-month post-surgery period with respect to the latter due to smokers’ higher rates of vascular diseases [40].

Moreover, among the behavioural factors, smoking is the best-studied risk factor in TKA [41,42,43], responsible for a higher risk of infection, surgical complications and mortality. In particular, some studies [44, 45] suggest that smoking may be associated with increased risk of aseptic loosening due to delayed bone healing and bone regeneration, which leads to subsequent revision of the implant. The data reported by Kunutsor et al. [46] showed a generally increased risk of periprosthetic joint infection (PJI) after total joint arthroplasty in smokers compared to non-smokers. Smoking can cause endothelial dysfunction, inflammation, progression of atherothrombosis and impaired systemic immune response, which are known to contribute to poor wound healing and subsequently to infection. However, following total knee arthroplasty, there is no evidence for an association between smoking and the risk of revision surgery [47], and smoking status does not seem to impact hospitalisation length of stay [48].

Just as for smoking, high alcohol intake is known to lead to higher postoperative complications, including PJI. However, no statistically significant association of age or high alcohol intake with risk of PJI has been described after total joint arthroplasties [46], while a significantly lower risk of revisions among patients who were at least moderate drinkers has been reported [57].

Although the results of this study were presented a few years after patient evaluation, they are still relevant because currently, similar surgical indications are given for individuals with knee OA, and the same knee prosthetic implant and rehabilitation protocols are still used.

One potential source of bias in our study was the use of only self-reported measurements of physical function and not performance-based tests, which are less influenced by psychologic factors, cognitive impairments and educational level [49]. Another limitation is that the study was single-centre based, meaning that its results should be confirmed by other investigations. Finally, although many traditional predictors of physical function were examined, the change from baseline values may have been affected by unmeasured variables that were not included in our analysis.

One of the study’s strengths was that we calculated a sample size that guaranteed a sufficient statistical power as opposed to most studies in this field characterised by small sample size [14]. We were, moreover, in the position to assess most of the traditional behavioural, demographic, biological and physical risk factors for physical function, permitting us to identify subgroups, such as current smokers, for a less biased interpretation of the overall results.

Conclusions

Our study shows that in patients with end-stage OA undergoing knee replacement surgery, 3-months after surgery QOL and physical function improved, according to both the SF-12 and the WOMAC–Index.

These findings demonstrate that surgery represents a valid approach to severe OA at any age, and that a comprehensive assessment, including patient-reported symptoms and outcomes, can help to identify risk and protective factors associated to physical function and QOL. Moreover, this study suggests that TKA should be considered the best surgical approach in case of severe knee OA pain, particularly in obese patients, irrespectively of age and OA stage.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

ADLs:

Activities of Daily Living

BMI:

Body Mass Index

CI:

Confidence interval

GDS:

Geriatric Depression Scale

GEE:

Generalised estimating equation

IQR:

Interquartile range

MCS:

SF-12 Mental component

MMSE:

Mini-Mental State Examination

OA:

Osteoarthritis

PCS:

SF-12 Physical component

PJI:

Periprosthetic joint infection

QOL:

Quality of life

QPro-Gin:

Quality of Life in Knee Prostheses

ROM:

Range of motion

SD:

Standard deviation

SE:

Standard error

SF-12:

Short-Form General Health Survey

TKA:

Total knee arthroplasty

UKA:

Unicompartmental knee arthroplasty

WOMAC:

Western Ontario and McMaster Universities Arthritis Index

References

  1. Carr AJ, Robertsson O, Graves S, Price AJ, Arden NK, Judge A, et al. Knee replacement. Lancet. 2012;379:1331–40.

    Article  PubMed  Google Scholar 

  2. NIH Consensus Panel. NIH consensus statement on total knee replacement December 8-10, 2003. J Bone Joint Surg Am. 2004;86:1328–35.

    Article  Google Scholar 

  3. National Joint Registry. 15th annual report; 2018. http://www.njrreports.org.uk/Portals/0/PDFdownloads/NJR%2015th%20Annual%20Report%202018.pdf. Accessed 27 Dec 2018.

    Google Scholar 

  4. Price AJ, Alvand A, Troelsen A, Katz JN, Hooper G, Gray A, et al. Knee replacement. Lancet. 2018;392:1672–82.

    Article  PubMed  Google Scholar 

  5. Beard DJ, Holt MD, Mullins MM, Malek S, Massa E, Price AJ. Decision making for knee replacement: variation in treatment choice for late stage medial compartment osteoarthritis. Knee. 2012;19:886–9.

    Article  CAS  PubMed  Google Scholar 

  6. Beard DJ, Davies LJ, Cook JA, MacLennan G, Price A, Kent S, et al. The clinical and cost-effectiveness of total versus partial knee replacement in patients with medial compartment osteoarthritis (TOPKAT): 5-year outcomes of a randomised controlled trial. Lancet. 2019;394:746–56.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Collier MB, Eickmann TH, Sukezaki F, McAuley JP, Engh GA. Patient, implant, and alignment factors associated with revision of medial compartment unicondylar arthroplasty. J Arthroplast. 2006;21:108e15.

    Google Scholar 

  8. Harrysson OLA, Robertsson O, Nayfeh JF. Higher cumulative revision rate of knee arthroplasties in younger patients with osteoarthritis. Clin Orthop Relat Res. 2004;421:162e8.

    Article  Google Scholar 

  9. Ingale PA, Hadden WA. A review of mobile bearing unicompartmental knee in patients aged 80 years or older and comparison with younger groups. J Arthroplast. 2013;28:262e7.

    Article  Google Scholar 

  10. Yohe N, Funk A, Ciminero M, Erez O, Saleh A. Complications and readmissions after Total knee replacement in octogenarians and nonagenarians. Geriatr Orthop Surg Rehabil. 2018;9:2151459318804113.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Vissers MM, Bussmann JB, Verhaar JAN, Busschbach JJV, Bierma-Zeinstra SM, Reijman M. Psychological factors affecting the outcome of total hip and knee arthroplasty: a systematic review. Semin Arthritis Rheum. 2012;41:576–5788.

    Article  PubMed  Google Scholar 

  12. Saracci R. The World Health Organisation needs to reconsider its definition of health. BMJ. 1997;314:1409–10.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Bachmeier CJ, March LM, Cross MJ, Lapsley HM, Tribe KL, Courtenay BG, et al. Arthritis cost and outcome project group. A comparison of outcomes in osteoarthritis patients undergoing total hip and knee replacement surgery. Osteoarthr Cartil. 2001;9:137–46.

    Article  CAS  Google Scholar 

  14. Kellgren JH, Lawrence JS. Radiological assessment of osteoarthrosis. Ann Rheum Dis. 1957;16:494–502.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Ware J Jr, Kosinski M, Keller SD. A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34:220–33.

    Article  PubMed  Google Scholar 

  16. Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 1988;15:1833–40.

    CAS  PubMed  Google Scholar 

  17. Ravussin E, Swinburn BA. Pathophysiology of obesity. Lancet. 1992;340:404.

    Article  CAS  PubMed  Google Scholar 

  18. Sheikh JI, Yesavage JA. Geriatric depression scale (GDS): recent evidence and development of a shorter version. Clin Gerontol. 1986;5:165–73.

    Article  Google Scholar 

  19. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–98.

    Article  CAS  PubMed  Google Scholar 

  20. Poitras S, Beaule PE, Dervin GF. Validity of a short-term quality of life questionnaire in patients undergoing joint replacement: the quality of Recovery-40. J Arthroplast. 2012;27:1604–8.

    Article  Google Scholar 

  21. Zhang Y, Zhang B, Wise B, Niu J, Zhu Y. Statistical approaches to evaluating the effect of risk factors on the pain of knee osteoarthritis in longitudinal studies. Curr Opin Rheumatol. 2009;21:513–9.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Kadam UT, Jordan K, Croft PR. Clinical comorbidity in patients with osteoarthritis: a case–control study of general practice consulters in England and Wales. Ann Rheum Dis. 2004;63:408–14.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Edwards MH, van der Pas S, Denkinger MD, Parsons C, Jameson KA, Schaap L, et al. Relationships between physical performance and knee and hip osteoarthritis: findings from the European project on osteoarthritis (EPOSA). Age Ageing. 2014;43:806–13.

    Article  PubMed  Google Scholar 

  24. Trevisan C, Veronese N, Maggi S, Baggio G, Toffanello ED, Zambon S, et al. Factors influencing transitions between frailty states in elderly adults: the Progetto Veneto Anziani longitudinal study. J Am Geriatr Soc. 2017;65:179–84.

    Article  PubMed  Google Scholar 

  25. Veronese N, Maggi S, Trevisan C, Noale M, De Rui M, Bolzetta F, et al. Pain increases the risk of developing frailty in older adults with osteoarthritis. Pain Med. 2017;18(3):414–27.

    PubMed  Google Scholar 

  26. Lin EH, Katon W, Von Korff M, Tang L, Williams JW Jr, Kroenke K, et al. Effect of improving depression care on pain and functional outcomes among older adults with arthritis: a randomized controlled trial. JAMA. 2003;290:2428–9.

    Article  CAS  PubMed  Google Scholar 

  27. Neuprez A, Neuprez AH, Kaux JF, Kurth W, Daniel C, Thirion T, et al. Total joint replacement improves pain, functional quality of life, and health utilities in patients with late-stage knee and hip osteoarthritis for up to 5 years. Clin Rheumatol. 2020;39(3):861–71.

    Article  PubMed  Google Scholar 

  28. Pandit H, Jenkins C, Gill HS, Barker K, Dodd CA, Murray DW. Minimally invasive Oxford phase 3 unicompartmental knee replacement: results of 1000 cases. J Bone Joint Surg (Br). 2011;93(2):198.

    Article  CAS  Google Scholar 

  29. Sun PF, Jia YH. Mobile bearing UKA compared to fixed bearing TKA: a randomized prospective study. Knee. 2012;19(2):103.

    Article  PubMed  Google Scholar 

  30. Bolognesi MP, Greiner MA, Attarian DE, Watters TS, Wellman SS, Curtis LH, et al. Unicompartmental knee arthroplasty and total knee arthroplasty among Medicare beneficiaries, 2000 to 2009. J Bone Joint Surg Am. 2013;95(22):e174.

    Article  PubMed  Google Scholar 

  31. Newman J, Pydisetty RV, Ackroyd C. Unicompartmental or total knee replacement: the 15-year results of a prospective randomised controlled trial. J Bone Joint Surg (Br). 2009;91(1):52.

    Article  CAS  Google Scholar 

  32. Fisher DA, Dalury DF, Adams MJ, Shipps MR, Davis K. Unicompartmental and total knee arthroplasty in the over 70 population. Orthopedics. 2010;33(9):668.

    PubMed  Google Scholar 

  33. Dalury DF, Fisher DA, Adams MJ, Gonzales RA. Unicompartmental knee arthroplasty compares favorably to total knee arthroplasty in the same patient. Orthopedics. 2009;32:4 orthosupersite.com/view.asp?rID=38057.

    Google Scholar 

  34. Willis-Owen CA, Sarraf KM, Martin AE, et al. Are current thrombo-embolic prophylaxis guidelines applicable to unicompartmental knee replacement? J Bone Joint Surg (Br). 2011;93(12):1617.

    Article  CAS  Google Scholar 

  35. Brown NM, Sheth NP, Davis K, Berend ME, Lombardi AV, Berend KR. Total knee arthroplasty has higher postoperative morbidity than unicompartmental knee arthroplasty: a multicentre analysis. J Arthroplast. 2012;27(8 Suppl):86–90.

    Article  Google Scholar 

  36. Lyons MC, MacDonald SJ, Somerville LE, Naudie DD, McCalden RW. Unicompartmental versus total knee arthroplasty database analysis: is there a winner? Clin Orthop Relat Res. 2012;470(1):84.

    Article  PubMed  Google Scholar 

  37. Labek G, Thaler M, Janda W, Agreiter M, Stöckl B. Revision rates after total joint replacement: cumulative results from worldwide joint register datasets. J Bone Joint Surg (Br). 2011;93(3):293.

    Article  CAS  Google Scholar 

  38. Dahl A, Robertsson O, Lidgren L, Miller L, Davidson D, Graves S. Unicompartmental knee arthroplasty in patients aged less than 65. Acta Orthop. 2010;81(1):90.

    Article  Google Scholar 

  39. Amis AA. Unicondylar knee replacement and the cruciate ligaments. In: Small implants in knee reconstruction. Milan: Springer Milan; 2013. p. 17.

    Chapter  Google Scholar 

  40. Gardner AW, Killewich LA, Montgomery PS. Katzel LI (2004) response to exercise rehabilitation in smoking and nonsmoking patients with intermittent claudication. J Vasc Surg. 2004;39:531–8.

    Article  PubMed  Google Scholar 

  41. Moller AM, Pedersen T, Villebro N, et al. Effect of smoking on early complications after elective orthopaedic surgery. J Bone Joint Surg (Br). 2003;85(2):178.

    Article  Google Scholar 

  42. Jorgensen CC, Kehlet H. Outcomes in smokers and alcohol users after fast-track hip and knee arthroplasty. Acta Anaesthesiol Scand. 2013;57(5):631.

    Article  CAS  PubMed  Google Scholar 

  43. Singh JA. Smoking and outcomes after knee and hip arthroplasty: a systematic review. J Rheumatol. 2011;38(9):1824.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Lim CT, Goodman SB, Huddleston JI 3rd, Harris AHS, Bhowmick S, Maloney WJ, et al. Smoking is associated with earlier time to revision of total knee arthroplasty. Knee. 2017;24(5):1182–6.

    Article  PubMed  Google Scholar 

  45. Sahota S, Lovecchio F, Harold RE, Beal MD, Manning DW. The effect of smoking on thirty-day postoperative complications after Total joint arthroplasty: a propensity score-matched analysis. J Arthroplast. 2018;33(1):30–5.

    Article  Google Scholar 

  46. Kunutsor SK, Whitehouse MR, Blom AW, Beswick AD. INFORM team. Patient-related risk factors for Periprosthetic joint infection after Total joint arthroplasty: a systematic review and meta-analysis. PLoS One. 2016;11(3):e0150866.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  47. Maradit Kremers H, Kremers WK, Berry DJ, Lewallen DG. Social and behavioral factors in Total knee and hip arthroplasty. J Arthroplast. 2015;30(10):1852–4.

    Article  Google Scholar 

  48. Ihekweazu UN, Sohn GH, Laughlin MS, Goytia RN, Mathews V, Stocks GW, et al. Socio-demographic factors impact time to discharge following total knee arthroplasty. World J Orthop. 2018;9(12):285–91.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Nielsen LM, Kirkegaard H, Østergaard LG, Bovbjerg K, Breinholt K, Maribo T. Comparison of self-reported and performance-based measures of functional ability in elderly patients in an emergency department: implications for selection of clinical outcome measures. BMC Geriatr. 2016;16:199.

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

We would like to express our thanks to Linda Inverso Moretti for assistance in editing the manuscript.

Funding

The study was not supported by any funder.

Author information

Authors and Affiliations

  1. National Research Council, Neuroscience Institute - Aging Branch, via Giustiniani, 2, 35128, Padova, Italy

    Paola Siviero & Stefania Maggi

  2. Aging Research Center, Karolinska Institutet and Stockholm University, SE-171 77, Stockholm, Sweden

    Anna Marseglia

  3. Orthopaedic Clinic, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padua, via Giustiniani 2, 35128, Padova, Italy

    Carlo Biz & Pietro Ruggieri

  4. Abano General Hospital, Abano Terme, Piazza Cristoforo Colombo 1, 35031, Abano Terme, PD, Italy

    Augusto Rovini & Roberto Nardacchione

Authors
  1. Paola Siviero
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  3. Carlo Biz
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  4. Augusto Rovini
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  7. Stefania Maggi
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Contributions

All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be published. PS had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study conception and design. PS, AM, SM. Acquisition of data. AM, AR. Analysis and interpretation of data. PS, AM, CB, AR, PR, RN, SM.

Corresponding author

Correspondence to Paola Siviero.

Ethics declarations

Ethics approval and consent to participate

The competent Ethical Committee of Padova (Comitato Etico per la sperimentazione clinica della Provincia di Padova c/o Servizio Farmaceutico Territoriale) approved the Quality of Life in Knee Prostheses (QPro-Gin) project (identifier: 258 OS). Written informed consent was obtained from all individual participants included in the study.

Consent for publication

Not applicable.

Competing interests

Carlo Biz is a member of Editorial Board of BMC Musculoskeletal Disorders.

No competing interests were reported by the other authors.

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Siviero, P., Marseglia, A., Biz, C. et al. Quality of life outcomes in patients undergoing knee replacement surgery: longitudinal findings from the QPro-Gin study. BMC Musculoskelet Disord 21, 436 (2020). https://doi.org/10.1186/s12891-020-03456-2

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Keywords

BMC Musculoskeletal Disorders

ISSN: 1471-2474

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