To Örebro University

BACKGROUND: Anxiety and depression are associated with patient dissatisfaction after total knee arthroplasty (TKA). Understanding whether preoperative knee-related symptoms could be a cause of anxiety and depression might help prevent unnecessary delay of surgery for this group of patients. We investigated changes in prevalence of anxiety and depression symptoms one year after TKA, and compared demographic data between patients with and without anxiety and depression symptoms preoperatively.

METHODS: This was a prospective cohort study of 403 patients scheduled for TKA. Data on patient-related outcome measures and the prevalence of anxiety and depression symptoms were collected preoperatively and one year postoperatively. Before-after differences in anxiety/depression prevalence were compared with a chi-square test, and differences in demographic data between the groups with and without anxiety and/or depression symptoms were compared with an independent t test.

RESULTS: Among the 15% of patients with anxiety symptoms before surgery, 59% had improved in these symptoms one year after surgery; while among the 10% with depression symptoms before surgery, 60% had improved one year after surgery. Patients with preoperative anxiety and/or depression were younger, and had higher body mass index, lower general quality of life (EQ-5D-3L), higher pain scores (visual analog scale), and lower knee-related (KOOS) scores on all subscales except sport.

CONCLUSION: Presurgical symptoms of anxiety and depression seem to be partly caused by knee symptoms. Understanding of this issue would offer better strategies to prevent unnecessary delay of surgery in this group of patients.

BACKGROUND: Total knee arthroplasty is a common procedure with generally good results. However, there are still patients who are dissatisfied without known explanation. Satisfaction and dissatisfaction 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 dissatisfaction rate.

METHODS: Of the 348 patients who responded to a letter asking if they were satisfied or dissatisfied with their surgery, 61 (18%) reported discontent. 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 1 year after total knee arthroplasty.

RESULTS: The patients experienced unfulfilled expectations and needs regarding unresolved and new problems, limited independence, and lacking of relational supports. They were bothered by pain and stiffness, and worried that changes were complications as a result of surgery. They described inability to perform daily activities and valued activities. They also felt a lack of relational supports, and a lack of respect and continuity, support from health care, and information adapted to their needs.

CONCLUSION: Patient expectation seems to be the major contributing factor in patient discontentment after knee replacement surgery. This qualitative study sheds light on the on the meaning of unfulfilled expectations, in contrast to previous quantitative studies. The elements of 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 satisfaction after surgery.

Introduction: Total knee arthroplasty (TKA) is effective in alleviating pain and improving function in patients with knee arthritis. Psychological factors are known to affect patient satisfaction after TKA. It is important to determine the effectiveness of TKA in patients with presurgical anxiety and/or depression to avoid excluding them from surgery.

Materials and methods: A prospective cohort study was conducted on all patients who underwent TKA during 2016-2018. Patients were divided into four groups: with anxiety, without anxiety, with depression, and without depression. Outcome measures comprised both generic and knee-specific instruments. Each patient group was compared regarding changes in outcome measures one year after surgery. Between-group comparison was also performed.

Results: Of the 458 patients with complete data, 15.3% and 9.6% had experienced presurgical anxiety and depression, respectively. All patient groups displayed statistical (P < 0.001) and clinical improvement in all outcome measures. Patients with presurgical anxiety and/or depression generally displayed less improvement, though the only significant mean differences concerned the Knee Injury and Osteoarthritis Outcome Score (KOOS)-sport score in the non-anxiety and non-depression groups (P = 0.006 and 0.03, respectively), a higher proportion of clinically improved KOOS pain in the non-anxiety group (P = 0.03), and the general health state in the anxiety and depression groups (P = 0.004 and 0.04, respectively).

Conclusions: All patients improved in outcome measures 1 year after TKA, regardless of presurgical psychological state. Patients with presurgical anxiety and/or depression benefit greatly from surgery and should not be discriminated against based on presurgical psychological distress, though this fact should not eliminate the preoperative psychological assessment of patients.

The overall aim of this thesis was to study patients with anxiety/depression symptoms before and after primary total knee replacement, particularly in terms of improvements in patients-reported outcomes, and particularly among those who were discontent with the surgery. This could hopefully improve patients' contentment after TKR.

Study I investigated the prevalence of knee symptom improvement among patients with preoperative anxiety and/or depression in comparison to patients who did not have anxiety/depression. Study II investigated changes in the prevalence of anxiety and depression one year after primary TKR. Study III investigated how TKR surgeons in Sweden informed their patients preoperatively, and what kind of information they gave. Study IV used face-to-face interviews to capture experiences of discontentment one year after TKR among patients without documented complications.

The main findings were that: 1. All patients improved in outcome measures one year after TKR, regardless of presurgical psychological state. 2. Among the 15% of patients with anxiety symptoms before surgery, 59% had improved in these symptoms one year after surgery; while among the 10% with depression symptoms before surgery, 60% had improved one year after surgery. 3. Knee surgeons in Sweden have considerable awareness of the importance of preoperative patient information, the impact of patient expectations, and psychiatric illness. However, they need to improve their preoperative routines when it comes to providing written information, asking about the patient’s expectations, and psychiatric assessment. 4. The patients experienced unfulfilled expectations and needs regarding unresolved and new problems, limited independence, and lacking relational support.