Why are patients discontented after total knee arthroplasty when the orthopedic surgeons are contented?

Total knee arthroplasty is a common procedure with generally good results. However, there are still patients who are discontented without known explanation. Contentment and discontentment have previously been captured by quantitative designs, but there is a lack of qualitative studies regarding these patients’ experiences. Qualitative knowledge might be useful in creating strategies to decrease the discontentment rate. Of the 348 patients who responded to a letter asking if they were contented or discontented with their surgery, 61 (18%) reported discontentment. After excluding patients with documented complications and those who declined to participate, semi-structured interviews were conducted with 44 patients. The interviews were analyzed according to qualitative content analysis. The purpose was to describe patients’ experiences of discontentment one year after total knee arthroplasty. regarding

unfulfilled expectations need to be dealt with both on the individual staff level and on the organizational level. For instance, increased continuity of healthcare staff and facilities may help to improve patient contentment after surgery.
Similarly, other qualitative studies showed the importance of patient participation, education, and information for satisfaction after TKA surgery [23,[32][33][34][35]. However, these studies are insufficient to describe the patient's experience of discontentment after TKA surgery.
Capturing knowledge about discontentment can provide complementary knowledge about contentment after TKA, and lead to practical strategies. We therefore aimed to use faceto-face interviews to capture patients' experiences of discontentment one year after TKA surgery.

Methods
The study was approved by the Regional Ethical Review Board of Uppsala, Sweden (ref: 2016/191 [2019-02077]). The participants gave written informed consent, and were informed that participation was on a voluntary basis and that they could withdraw from the study at any time. Confidentiality was guaranteed.
This study had a qualitative approach with an inductive design [38]. All 356 patients who had undergone primary TKA in 2015-2016 at three hospitals in central Sweden were sent a letter one year after surgery, asking whether they were "contented" or "discontented" with the TKA. Of the 348 who responded, 61 (18%) reported discontentment. Seven patients were excluded due to documented postoperative complications, and a further ten declined to participate for logistical reasons such as difficulty coming to the interview, illness, or late response, and so the final sample consisted of 44 persons (Figure 1). Table   1 shows an overview of the demographic and clinical characteristics of the study participants. The word "discontented" was used instead of "dissatisfied" because the participants commented that they were not totally dissatisfied with the surgery.
Semi-structured face-to-face interviews were conducted at locations chosen by the participants; either in the hospital or at their homes. The first author (AM), who is an orthopedic surgeon, conducted all but one of the 44 interviews. The last author (MHN) conducted one interview because the participant was the first author's patient. The two main questions were "Can you tell me about the time before surgery?" and "Can you tell me about the time after surgery?". Follow-up questions such as "Please tell me more about that," or "Can you give an example?" were used. The audio-recorded interviews varied between 15 and 57 minutes (mean 35 minutes) and were transcribed verbatim by a professional secretary.
The interviews and transcripts were analyzed by means of qualitative content analysis with an inductive approach [38]. Version 11 of the NVivo software package (Boston, MA, USA) was used to facilitate the categorization. Each interview was listened to while reading the text, and the transcripts were read meticulously. Meaning units that related to the aim of the study were extracted and condensed, and then a code was created for each condensed meaning unit. In the next step, the codes were compared for similarities and variations and sorted into sub-categories. The sub-categories were grouped into generic categories, and finally a main category emerged. Data analysis was initiated by the first author (AM), but the progress of each step in the analysis was scrutinized and discussed between AM and MHN. The analysis was co-assessed by MS and then iteratively revised between these three authors until final agreement was established.
Participants regret to surgery were also investigated as it might indicate participant´s discontentment to TKA surgery. The percentage presented at the end of the results section.

Results
One main category emerged to cover the patients' experiences of discontentment after TKA: unfulfilled expectations and needs. The patients described unresolved and new problems, limited independence, and a need for buttresses from healthcare ( Figure 2).

Unresolved and new problems
The participants said they were bothered by pain and stiffness. They expressed disappointment over suffering from existing and new pain as well as the pain having lasted longer than expected. Despite the preoperative information that pointed out the likely extent and duration of the postoperative pain, which could be expected to last up to one year from the index surgery, some were discontented due to having experienced continued pain for a long time. Some expressed discontentment despite being pain free now. Pain at night and at rest was described as uncomfortable and worrisome. The participants described discomfort that encompassed the whole knee. Disappointment was expressed over insufficient pain relief, the fact that medication could not soothe the postoperative pain, and that it did not subside in the first few months. The participants described how disturbed they were with the continual pain, and said that the pain was sometimes so intense that they were unable to do their knee exercises. The onset of new pain when performing their usual activities and movements created frustration. This kind of pain was described as continuing for several months after surgery, and was experienced as bothersome.
Discontentment with annoying and long-lasting stiffness was another experience often mentioned by the participants. They expressed their disappointment over not being able to bend and straighten the knee as expected, and said that their knee joint did not feel the same as before. Difficulties getting up from chairs and an inability to kneel for a long time were also mentioned as sources of discontentment. New or aggravated problems from other parts of the body were also a cause of discontentment, including increased back pain, continued hip pain, pain in the other knee, and pain and swelling in the foot. The participants worried that these changes were symptoms of complications.
The longevity of the long-term after-effects caused the participants to worry and dwell on ongoing complications. Complications that occurred during surgery or a consequence of the surgery were dreaded. The participants said that they worried something was wrong because of, for example, long-lasting pain, swelling, stiffness, and clicking sounds.
Numbness, including lack of sensation or no sensation at all after surgery, was described as worrying. The participants worried over whether this was a complication or adverse event.
"Yeah it's…how should I say…What's better with the right knee is that I have more feeling…in the left knee, the feeling has disappeared on the outside, below the knee."

(Participant 10)
Some of the participants thought that a part of their knee prosthesis was sitting wrong, while others described how they thought they had a detached ligament, fracture, infection, or thrombosis, or that the implant had started to loosen. A few were worried because the knee prosthesis was foreign material that might initiate an inflammatory response or develop into cancer. Most of these participants realized the complexity of a second operation and the subsequent greater risk for complications. Some expressed the fear that they would have to permanently use a wheelchair.

"… it can trigger cancer and such things [inflammation and infection] …the dentist says that if you've had a knee operation then you can't do this and that." (Participant 28)
Limited independence 8 The participants described how their symptoms hindered them from valued activities.
They had expected that after surgery these activities would no longer be a problem, or at least be easier.
Difficulties performing normal daily activities included standing to wash dishes, vacuum cleaning, cutting the grass, working in the garden, driving a car, or performing their jobs; symptoms that were mentioned as obstacles in performing these activities were pain, stiffness, swelling, weakness in the leg, and not being able to trust the knee. The participants expressed disappointment over not being able to walk reasonable distances without difficulty or pain after surgery, and felt that it was a realistic expectation to be able to walk normally a year after the surgery. However, they did realize the negative impact that running and jumping would have on the artificial knee. They described different degrees of walking difficulties: some needed to use crutches or walking sticks, some had difficulties walking on uneven as well as flat surfaces, and some had to have a rest after 100 or 250 meters.
They also expressed disappointment with their inability or difficulty in performing their favorite recreational activities, such as biking, dancing, hunting, fishing, playing golf, skiing, hiking, swimming, picking berries in the forest, and playing with their grandchildren. Every participant had their own favorite recreational activity or activities, and they spoke about how they had looked forward to resuming these activities after their knee replacements. They described these activities as reasonable for their ages, and noted that there were many elderly people who could perform these activities without problems. Their incapacity for doing these activities was experienced as depressing and disappointing.

Need for buttresses
The participants described experiencing a lack of respectful interaction from the healthcare staff. For instance, they spoke about how the orthopedic surgeons would enumerate how expensive the surgery was or how the patient was to blame for their knee problem because of their obesity. They also pointed out that when the doctor did not introduce self before surgery, the doctor-patient relationship was damaged and insecurity in the relationship ensued.  Participants had previously thought that TKA was a major surgery that required several days in the hospital, and were worried over the short hospitalization. They were surprised to be scheduled for surgery on the morning they arrived at the hospital, and said that being discharged on the same day or shortly thereafter caused a sense of insecurity, especially when they were not discharged by the same doctor they had previously seen and who performed the surgery.
The participants said they thought individuals should have individually-adapted treatment, and were discontented when they believed they were not getting it. They said they were made to feel they were a bother to the doctors.
Lack of continuity was another source of discontentment. The participants explained how having the same doctor all the time was not only important, but a vital part of health care.
They were rather disappointed when they did not meet their doctor after the surgery and/or at the follow-ups. Participants who were operated on by a different surgeon than the one they were familiar with also voiced discontentment. Some described it as degrading and showing lack of respect. The participants also expressed the importance of continuity with the physiotherapist and with the level of care. They felt it inappropriate for patients who had undergone such major surgery to be sent back to their local primary care clinic for follow-ups. They recommended that telephone contact and/or a follow-up visit with the same doctor should be standard procedure.
The lack of individualized training was another unfulfilled need. The participants pointed out the importance of professional, organized, motivated, well-informed, and regular physiotherapy, both pre-and post-operatively, and experienced deviations from these principles as a cause of discontentment. Some of them blamed their perceived poor outcome on the physiotherapist. The lack of motivation for training before and after surgery was also mentioned as causing the perceived poor results. The participants realized the importance of training during the year after surgery, but they lacked the motivation. However, they blamed others who they felt had the knowledge and responsibility to motivate them.
The participants wondered if they had fallen between the cracks in the healthcare system. Some of them criticized the lack of cooperation between the different healthcare facilities responsible for patient care before and after surgery. Sometimes there were disagreements among the facilities, which had a negative impact on the patient. The participants particularly stressed the importance of communication and cooperation between the primary care clinic, the orthopedic department, the different specialists, and the social insurance agency. Limited finances or lack of economic support increased the participants' feelings of insecurity and discontentment. Most of the financial challenges were related to a prolonged or total inability to return to work, particularly when the insurance agency declined additional support. In some cases, patients who were unable to return to their previous long-term work were asked by the insurance agency to get a different type of job; those who found this impossible then experienced financial difficulties. Added to this were the charges incurred from the continued physiotherapy, doctor visits, and medication.

What should I switch to? …" (Participant 14)
Discontentment arose over a lack of information regarding the surgery and expected recovery. Some of the participants reported they had wanted more information regarding the risks involved with the surgery and other alternatives to the surgery. The information was experienced as too general in scope, and did not address what each individual patient could expect. One area the participants felt needed addressing was the lack of information regarding the individual training program before and after the surgery.

"Yes, yes, I probably should have had [individual information]. I did get a pamphlet to read, but it doesn't discuss that sort of stuff. Instead, it was mostly about how a person should move and which movements you should do and such." (Participant 5)
The participants described partial or total regret over having had the surgery. Ten of them (22%) totally regretted the surgical procedure, meaning that the incidence of patients who totally regretted TKA surgery in the absence of complications was 2.9% (10/348). These ten, who included both men and women, said that not only were their expectations unfulfilled, but also new problems and ailments had developed and old ones had worsened considerably after the surgery.
"I regretted it many times actually. Yeah…the pain was much less before the surgery, than now. Yeah… even if I had major pain and was stiff and such, it was less than this pain, much easier than this pain." (Participant 1) Those participants who expressed partial regret after the surgery did not think the aftercare and results were that worthwhile, and concluded that perhaps they should have postponed the surgery a bit longer.

Discussion
This study reveals that the expectations and needs of these discontented patients were not met after knee replacement surgery. The participants described unresolved and new problems, a need for buttresses, and limited independence.
Patients' expectations have previously been shown to play an important role in postoperative contentment [8,9,19,22,24,28,29,31,37,39], but these studies do not define the patients' expectations, nor do they explain how to address them. The studies do agree about using individualized enquiry regarding patient expectations. Greene et al.
recommended preoperative patient education, multimodal pain management, and aggressive postoperative rehabilitation to better meet patients' expectations [8]. The participants each had activities that they expected to be able to perform at least as well as, or better than, before the surgery, and were rather disappointed when these expectations were not met. These expectations need to be deeply explored and defined before surgery to increase patient satisfaction rates in the future. This idea is supported by previous studies which concluded that it is not enough to relate satisfaction to expectations of activities in general terms, but that this should be done on a more personal and specific basis [22,24,28].
Patient information plays an important role in patient contentment after surgery. Many studies have shown the positive effects of patient education and information given before surgery [17,18,35,36,40,41]. The importance of information and lack of information was made clear by the discontented participants in our study. Although the participants said they were satisfied with the information preoperatively, they were not content with it postoperatively. The discontented participants explained that with more individualized and in-depth information, they could perhaps understand what might have gone wrong and led to their physical complaint. The other obvious type of information that was missing had to do with their recovery. This was mentioned by most of the participants, which could indicate a considerable problem. All the participants admitted they were told that it would take at least a year after the surgery to see the results, but they said they would have preferred more individualized and detailed information. Many participants expressed relief at the end of the interview when the researcher offered them an opportunity to receive more information and ask questions regarding their TKA.
It is possible that the participants in our study were discontented because they were not fully informed regarding the somewhat limited range of motion that could be expected postoperatively. A recent study showed that an improvement of five degrees in the range of motion in the knee after surgery along with an improved walking distance could increase the satisfaction rate by 6-8 times [42]. Other studies also agree with the effect of stiffness on satisfaction [43,44].
Our discontented participants expressed anxiety and worry over complications. They saw the longevity of symptoms after surgery as a sign of untoward surgical complications. This might explain why they complained about insufficient follow up and lack of information after surgery. This issue needs to be deeply explored to reduce patient anxiety and minimize discontentment. Our participants also experienced anxiety over the short hospitalization after the TKA, as they had had the impression that the surgery was so major that one or two days would be insufficient. They had not been sufficiently informed and prepared regarding this preoperatively. However, many studies have shown that "fast track" TKA procedures, with discharge on the day of surgery or the day after, are associated with good satisfaction rates [45][46][47]. We did not differentiate between fast track and conventional surgeries, so we cannot say if our results regarding the percentage of discontentment differ from these other study populations. However, because those studies were focused on investigating fast track surgeries, preparation of the patients was perhaps more rigorous and therefore yielded less discontentment in that area, which would be reflected in the overall results.
Pain is the most common factor indicating the need for surgery [48], and is suggested to be the most common cause of dissatisfaction after knee arthroplasty [9,15,16]. In our study, participants expressed their anxiety about long-lasting pain. The participants considered postoperative pain lasting more than 3 months to be long-term postoperative pain as pain that lasts more than 3 months. Many participants mentioned varying points of time for when the new onset of pain in the knee occurred after the surgery. They explained how this pain had a new character that did not subside after the wound had healed, said that the pain disturbed their sleep and certain activities, and described the pain as disappointing, unexpected, worrying, and bothersome.
The need for support and buttresses during their journey played an important role in the participants' contentment. When they experienced disrespectful interactions with the healthcare staff, they felt degraded and insulted. This could occur throughout the process, and it did not seem to make a difference when. The need for good interaction between the patient and healthcare staff to improve contentment after surgery is supported in the literature [7,28,35]. On the other hand, lack of social support was more pronounced after surgery. Participants experienced the greatest need for physical, psychological, social, and economic buttresses during the first six months after surgery. A lack of understanding from the insurance agency was worsened by poor communication among the responsible healthcare facilities. Consequently, the patients felt vulnerable without support, which led to discontentment even when they improved clinically afterwards. Weinberg et al. highlighted this issue in a study of patients who experienced problems between themselves and different settings or providers [49]. Lacking continuity in the healthcare team was experienced as troubling in many aspects. One of these was that when the surgeon gets to know the patient well they can undoubtedly better explain the issues related to surgery. This is important, because the participants who reported continued pain and suffering worried that something untoward had occurred. Positive patient experiences and contentment after lower extremity arthroplasty have been shown to be closely linked to effective interactions between the patients and the healthcare professionals [50]. To our knowledge, no previous study has addressed orthopedic surgeon continuity and patient contentment; this could be a useful issue for future research.
Limitations, strengths, and trustworthiness of the study A major strength of using a qualitative method is that it allowed us to capture the content of discontentment. This can serve as a basis for or complement to quantitative study designs, since it provides an understanding of the complexity of discontentment after TKA surgery. The results can be transferred to similar situations or patients, since the participants and context are thoroughly described. Credibility was strengthened by using direct quotations from the participants, and having three different researchers code and analyze the parts of the interviews independently. Dependability was enhanced by the use of triangulation in the agreement of coding and analysis, as well as representation of data from three hospitals. Conformability was ensured by meticulous data analysis by three of the authors (AM, MHN, and MS) The large number of interviews (n=44) could be argued both as a weakness and as a strength. On one hand, it can be difficult to grasp the whole of such a large material, and the amount of new findings decreases for every interview after about the first 15 [38]. On the other hand, the large amount of information from these interviews can be seen as representative of this group of discontented patients, and hence the findings can be transferred to similar knee replacement populations.
The fact that the first author (AM) was an orthopedic surgeon and conducted all but one of the 44 interviews can also be viewed as both a weakness and a strength. The researcher's preunderstanding can be a strength in that it means being familiar with the context and knowing what to ask, but it could also be a weakness if the researcher is not able to see beyond their preconceptions. Another weakness might be that the relationship risks becoming more of a doctor-patient relationship than an interviewer-participant relationship, in that the patient might be inhibited by respect. However, the interviewer used a low profile and had a respectful attitude, and he felt that the informants could express discontentment freely. Additionally, he wore everyday clothing and held the interviews outside the orthopedic department.

Conclusion
Discontentment after total knee arthroplasty is a complex problem with many intertwining factors. Although the participants shared common wishes and needs after surgery, they had their own expectations and points of view regarding factors that can lead to the success of surgery. These factors need to be explored and addressed with each individual patient. The elements of unfulfilled expectations need to be dealt with both on the level of individual staff and on the organizational level. For instance, increased continuity of healthcare staff and facilities may help to improve patient contentment after TKA surgery.
Patient contentment is a process that starts with the first contact before surgery and continues until the patient decides it is complete. Further research is needed to quantitatively analyze the discontentment factors that emerged from this study.

List Of Abbreviations
TKA: Total knee arthroplasty Declarations Ethics approval and consent to participate The study was approved by the Regional Ethical Review Board of Uppsala, Sweden (ref: 2016/191 [2019-02077]). The participants gave written informed consent, and were informed that participation was on a voluntary basis and that they could withdraw from the study at any time. Confidentiality was guaranteed.

Consent for publication
Not applicable.

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

Funding
This study was funded by the Örebro Research Committee, Sweden, and the Orthopaedic Department, Karlskoga Hospital, Sweden. No external funding or benefits were received.
The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication Authors' contributions AM created the study protocol and design, interviewed 43 participants,collected the data, performed the analysis, and wrote the manuscript. MHN contributed to the study design, the analysis, revision of the manuscript and interviewed one participants. MS contributed to the study analysis, and big role in the revision of the manuscript. PW contributed to the study design, data collection and revision of the manuscript.  Sub-categories, generic categories, and main category describing patients' experiences of discontentment after TKA surgery This figure shows the tree of the study results. This tree emerged from the coding process of the participants' interview.