PICKING YOUR PATIENT: “A VERY PERSONAL EXPERIENCE”

Abstract

The overall success or failure of total knee arthroplasty (TKA) is predicated upon the successful combination of appropriate patient selection, proper meticulous surgical technique, and correct prosthetic design. The majority of discussions regarding the outcome of TKA seem to be focused on the hardware utilised and the surgical technique employed. Little attention is given to choosing the correct patient for this operative intervention. Consider some intuitive examples: 1.) patients with a diagnosis of osteoarthritis are less prone to perioperative complications than patients with rheumatoid arthritis; 2.) the greater the degree of preoperative combined varus/valgus deformity and flexion contracture, the more difficult the operative intervention and subsequent postoperative physical therapy and rehabilitation; 3.) it has been well documented that preoperative range of motion, as well as pre-existing flexion contractures, are the best determinant of postoperative range of motion; 4.) the presence or absence of secondary gain via manipulation of loved one or the status of a worker’s compensation claim will have a direct effect on the patient’s ability to recover successfully from the operative intervention; and 5.) the ability of the patient to participate in the postoperative physical therapy and rehabilitation program, as determined by either motivational status, postoperative depression, or cognitive ability will directly impact the result of the TKA. These examples are illustrative of the importance of optimising the doctor-patient relationship and of providing additional resources to the patient, especially a well-organised team.

The patient must be informed that the ultimate outcome of TKA is multi-factorial and that he/she plays a significant role in determination of that outcome. The ideal candidate for TKA is the patient who presents with incapacitating pain resulting in alteration of lifestyle in spite of the utilisation of conservative modalities. Clinical evaluation documents the presence of effusion with a painful range of motion and antalgic gait pattern. In addition, roentgenographs reveal advanced arthrosis. Complete preoperative medical evaluation is mandatory to delineate co-morbidities and to optimise the patient’s preoperative status for the surgical intervention. Careful assessment of the preoperative norvascular status of the extremities may serve to prevent postoperative complications. Preoperative evaluation and discussion should focus not only on the actual operative intervention and perioperative complications, but should also include a thorough discussion of postoperative pain management, as well as the expectations that will be placed upon the patient. The importance of motivation to participate in the postoperative physical therapy and rehabilitation program and to follow the directives of the physician, nurses, and physical therapist must also be stressed. Patients should also be cognizant of the fact that there is a delicate balance between over activity and under activity in the postoperative period. The patient’s experience may only be fully appreciated when the physician becomes a patient and experiences the consequences of TKA firsthand. This offers the surgeon a greater insight into patients’ expectations, the importance of preoperative counselling, the severity of perioperative pain, as well as the difficulty in dealing with postoperative swelling, mobilisation, range of motion, and the struggle to the return to activities of daily living. In summary, the quality of the outcome of TKA is dependent on the harmony that exists between the patient’s perioperative status and expectations, the physician’s diagnostic, surgical, and motivational skills, and the characteristics of the prosthesis.