Aims. Patient dissatisfaction following primary total knee arthroplasty (TKA) with manual jig-based instruments has been reported to be as high as 30%. Robotic-assisted total knee arthroplasty (RA-TKA) has been increasingly used in an effort to improve patient outcomes, however there is a paucity of literature examining patient satisfaction after RA-TKA. This study aims to identify the incidence of patients who were not satisfied following RA-TKA and to determine factors associated with higher levels of dissatisfaction. Methods. This was a retrospective review of 674 patients who underwent primary TKA between October 2016 and September 2020 with a minimum two-year follow-up. A five-point Likert satisfaction score was used to place patients into two groups: Group A were those who were very dissatisfied, dissatisfied, or neutral (Likert score 1 to 3) and Group B were those who were satisfied or very satisfied (Likert score 4 to 5). Patient demographic data, as well as preoperative and postoperative patient-reported outcome measures, were compared between groups. Results. Overall, 45 patients (6.7%) were in Group A and 629 (93.3%) were in Group B. Group A (vs Group B) had a higher proportion of male sex (p = 0.008), preoperative chronic opioid use (p < 0.001), preoperative psychotropic medication use (p = 0.01), prior anterior cruciate ligament (ACL) reconstruction (p < 0.001), and preoperative symptomatic lumbar spine disease (p = 0.004). Group A was also younger (p = 0.023). Multivariate analysis revealed preoperative opioid use (p = 0.012), prior ACL reconstruction (p = 0.038), male sex (p = 0.006), and preoperative psychotropic medication use (p = 0.001) as independent predictive factors of patient dissatisfaction. Conclusion. The use of RA-TKA demonstrated a high rate of patient satisfaction (629 of 674, 93.3%). Demographics for patients not satisfied following RA-TKA included: male sex, chronic opioid use, chronic psychotropic medication use, and prior ACL reconstruction. Patients in these groups should be identified preoperatively and educated on realistic expectations given their comorbid conditions. Cite this article: Bone Jt Open 2024;5(9):758–765

Sub-acromial decompression surgery (SAD) has been widely used to treat shoulder impingement. Its validity has been questioned in multi-centric clinical trials and dissatisfaction rates can be high (35%). It is difficult to predict which patients will benefit operatively as research into predictive factors is limited. The study aim was to conduct a root-cause analysis of reasons for dissatisfaction in a cohort of operated patients. All patients with SAD dissatisfaction in the local Upper Limb database between 2015-19 (n=74/296) formed our study cohort. Patients were scored on Oxford shoulder score (OSS), QuickDASH score, EQ-5D-3L (TTO+VAS) at weeks 26 and 52 post-operatively. Patients' clinical history, radiographs, consultation and operative notes were reviewed. 28% of patients were dissatisfied with surgery. Mean age =52.3±13.4 years with equal gender distribution. 87% were operated arthroscopically. 67% were in physically demanding occupations. There was a significant increase in OSS and QuickDASH at weeks 26 and 52 post-operatively (p<0.05), similar improvement was not noted in VAS pain score. Pain followed by stiffness were the main contributors of dissatisfaction. Multiple implicating factors were noted, the most common being acromio-clavicular joint arthritis (25.7%), suggesting concomitant pathologies as an additional cause for patient dissatisfaction. This is the first study to evaluate reasons for dissatisfaction following SAD. We noted high rates (28%) of dissatisfaction and a predilection for those involved in physically demanding occupations. We recommend meticulous pre-operative workup to identify co-existing pathologies and appropriate pre-operative counselling to improve outcomes in selected patients needing SAD following failure of conservative management

Risk of revision following total knee replacement is relatively high in patients under 55 years of age, but little is reported regarding non-revision outcomes. This study aims to identify predictors of dissatisfaction following TKR in patients younger than 55 years of age. We assessed 177 TKRs (157 consecutive patients) from 2008 to 2013. Data was collected on age, sex, implant, indication, BMI, social deprivation, range of motion, and prior knee surgery in addition to Oxford Knee Score (OKS) and SF-12 score. Postoperative data included knee range of motion, complications, and OKS, SF-12 score and satisfaction measures at one year. Overall, 24.9% of patients (44/177) were unsure or dissatisfied with their TKR. Significant predictors of dissatisfaction on univariable analysis (p<0.05) included: Kellgren-Lawrence grade 1/2 osteoarthritis; indication; poor preoperative OKS; postoperative complications; and poor improvements in OKS and pain component score (PCS) of the SF-12. Odds ratios for dissatisfaction by indication compared to primary OA: OA with previous meniscectomy 2.86; OA in multiply operated knee 2.94; OA with other knee surgery 1.7; OA with BMI>40kgm-2 2; OA post-fracture 3.3; and inflammatory arthropathy 0.23. Multivariable analysis showed poor preoperative OKS, poor improvement in OKS and postoperative stiffness, particularly flexion of <90°, independently predicted dissatisfaction (p<0.005). Patients coming to TKR when under 55 years of age differ from the ‘average’ arthroplasty population, often having complex knee histories and indications for surgery, and an elevated risk of dissatisfaction

The Trent Arthroplasty Audit Group (TAAG) is an arthroplasty register set up over ten years ago to record data on all hip and knee arthroplasties performed in the Trent region. This currently serves a population of 5.16 million with an average of 10,000 arthroplasties recorded each year. Patients are sent a postal questionnaire at one year post surgery to record satisfaction with surgery amongst some of its parameters. We analysed the questionnaires returned on patients having undergone primary knee arthroplasties during the years 97/98. Those recording a poor satisfaction score were then analysed to see if any trends emerged and thus achieve our aim of improving overall satisfaction scores within Trent. In 1997/98, 3219 primary knee replacements were perfomed in Trent, of which 241(12%) recorded a poor satisfaction rating. Analysing this group, 30% of patients had no clinically identifiable cause for their dissatisfaction. No correlation between type of implant used could be suggested. In 28% of patients the surgeons were unaware of their patients’ dissatisfaction in clinic. Bilateral arthroplasties had been performed in 25% of the dissatisfied group. Re-evaluating this group 4 years post-op, improved their dissatisfaction to 7%. Our study indicates that a high proportion of patients (12%), undergoing knee replacement surgery record a poor satisfaction score at one year post-op. The respective consultants were unaware of any problem in 30% of cases, despite follow up. This rating improved to 7% without intervention in many cases. We suggest that this may be due to high expectations and appropriate pre-operative counselling needs to be undertaken before such surgery

Up to 20% of patients are not satisfied with the outcome following total knee replacement (TKR), but little is known about the predictors of this dissatisfaction. This study investigated the pre- and post-operative predictors of dissatisfaction in a large cohort of patients undergoing TKR. We assessed 1217 consecutive patients undergoing TKR between 2006 and 2008 both preoperatively and six months after surgery, using the Short-form (SF)-12 health questionnaire and the Oxford Knee Score. Detailed co-morbidity information was also gathered. Satisfaction was measured at one year and 18.6% (226 of 1217) of patients were unsure or dissatisfied with their replacement, 81.4% (911 of 1217) were satisfied or very satisfied. Multivariate regression analysis was performed to identify independent predictors of dissatisfaction. Significant (p < 0.001) predictors of dissatisfaction at one year included the pre-operative SF-12 mental component score, the co-morbidities of depression and pain in other joints, and the six-month SF-12 score. The most significant independent predictor of dissatisfaction at 1 year was poor improvement in Oxford Knee Score pain element at 6 months. Patient expectations were highly correlated with satisfaction. Satisfaction following TKR is multifactorial. Managing patient expectations and mental health may reduce dissatisfaction rates. However, the most significant predictor of dissatisfaction is a painful total knee replacement

TKA is among the fastest growing interventions in medicine, with procedure incidence increasing the most in younger patients. Global knee scores have a ceiling effect and do not capture the presence of difficulty or dissatisfaction with specific activities important to patients. We quantified the degree of residual symptoms and specific functional deficits in young patients who had undergone TKA. In a national multicenter study, we quantified the degree of residual symptoms and specific functional deficits in 661 young patients (mean age, 54 years; range, 19–60 years; 61% female) at 1 to 4 years after primary TKA. To eliminate observer bias, satisfaction and function data were collected by an independent, third-party survey center with expertise in administering medical outcomes questionnaires. Overall, 89% of patients were satisfied with their ability to perform normal daily living activities, and 91% were satisfied with their pain relief. After TKA, 66% of patients indicated their knees felt normal, 33% reported some degree of pain, 41% reported stiffness, 33% reported grinding/other noises, 33% reported swelling/tightness, 38% reported difficulty getting in and out of a car, 31% reported difficulty getting in and out of a chair, and 54% reported difficulty with stairs. After recovery, 47% reported complete absence of a limp and 50% had participated in their most preferred sport or recreational activity in the past 30 days. When interviewed by an independent third party, about 1/3 of young patients reported residual symptoms and limitations after modern TKA. We recommend informing patients considering surgery about the high likelihood of residual symptoms and limitations after contemporary TKA, even when performed by experienced surgeons in high-volume centers, and taking specific steps to set patients’ expectations to a level that is likely to be met by the procedure as it now is performed

The concept under discussion is curious and central to our work: is patient dissatisfaction with modern TKA really a “growing problem”? Could it be, that as our technique and technology have improved function and durability, that surgical results have become worse????. A disappointing percentage of patients polled from a distance are less than fully satisfied with the results of their surgery. Why does this surprise us as surgeons?. This problem needs to be untangled. First, these studies ask patients blankly if they are satisfied with their surgery, generally and with respect to specific criteria (e.g. activities of daily living). Neither the patients nor their radiographs have been evaluated. Undoubtedly, some dissatisfied patients will have arthroplasties that would be assessed as less than perfect by a comprehensive evaluation that might include stability testing, range of motion and radiographs of patellar tracking, including CT examination for rotational positioning of components. Some will have suffered the recognised complications of surgery such as chronic regional pain syndrome and infections which, while treated, often yield poor results. Surgeons all too often abandon a systematic and comprehensive evaluation, almost dismissing patients who complain. A second group will be disabled due to physical factors extrinsic to the arthroplasty: polyarthritis, deconditioning and medical comorbidities. Others suffer depression and are disappointed that life never improved after the arthroplasty. Thirdly, another group will have knees that could not technically have been any better, but who are still dissatisfied with the result. Some had expectations that exceeded the capability of current technology to reproduce knee function. Their surgeons failed to convey the potential of arthroplasty to make things “normal” in a way that the patient could incorporate. Other patients may have submitted to surgery prematurely, before arthritis and knee dysfunction, had reached the point where arthroplasty represents an improvement. The concept of a “growing problem”, has more to do with the disjunction between rapidly accelerating public expectations (fueled by modern medicine) and the more modest rate of progress in technology, technique and education. Happy patients tend to be satisfied and there are a great many factors that determine happiness. Assessment depends on tools for measurement. Surgeons have struggled honestly to develop tools that could help assess which prostheses and techniques were superior, to make wise choices in developing techniques and implants. Many of the original clinical assessment tools have been challenged as invalid. Newer more comprehensive tools have been developed. The “evidence based” movement, and rejection of some clinical tools, represents a shift in power in clinical medicine that has “enabled payers, purchasers, and governmental authorities to use their financial clout to alter the practice of medicine.” (. http://www.ahrq.gov/research/findings/evidence-based-reports/jhppl/rodwin.html. ). This information is a call for practitioners to evaluate dissatisfied individuals compassionately and objectively and for investigators to evaluate the entire problem exhaustively. Skepticism is appropriate when this message is a glib pretext for commercialisation and/or for denigration of the role of arthroplasty in the lives of our patients. It is a call to improve, not abandon our craft

Despite the widely accepted advantages of total knee arthroplasty surgery, not all patients are completely satisfied. This was initially reported with studies from the Swedish Registry and indicates room for improvement in our craft. But who says this is a “growing concern”? First of all are the third party payers and government agencies who would like to curtail expenditures and retain funds. Next are manufacturers promoting new, and one would hope, improved products and finally surgeons similarly promoting new techniques.

But who are the minority of dissatisfied patients and why are they unhappy? There is no reduction in demand for arthroplasty surgery by patients worldwide.

Abstract. Abstract:. Background. The dissatisfaction rate in patients operated with TKR is generally quoted to be around 20% in various registries in patients operated by multiple surgeons. The data of satisfaction rates following a TKR performed by single high volume surgeons is lacking. Aim. To study the satisfaction rate and Net Promoter Score (NPS) of consecutively operated TKR patients by a single surgeon with a minimum 1 year follow up. Methods. 860 out of 883 patients who were operated between 1st April, 2018 and 31st March, 2019 were contacted by a telephonic call. They were asked 3 questions related to their experience about the operation. The patient satisfaction, NPS and reason for dissatisfaction were assessed. Results. The overall satisfaction rate of 95.93% and a net promoter score of +96.63 was observed. When the NPS was calculated as the worst case scenario, a score of +93.70 was observed. 6 patients were unsatisfied with causes directly related to the surgery. Conclusion. TKR can have as high satisfaction rates with very high NPS in experienced surgical hands using standard techniques. These results may form a benchmark against which newer technologies can be compared

Introduction. Patient satisfaction is an important outcome measure after total knee arthroplasty (TKA) and is the ultimate goal of surgery. However, patient satisfaction reflects a complex construct of the patient's personal expectations and preferences in addition to subjective evaluation of outcome after TKA. Multiple studies have found a patient dissatisfaction rate of approximately 20% at 1 year after TKA. The purpose of this study is to determine whether there is an association between a single-item validated TKA satisfaction score and patient-reported outcome measures (PROMs) at 3 time points (1, 2, and 5 years after TKA) and to determine if dissatisfaction rate after TKA varies over time. Methods. A multi-center, prospective cohort of 12,952 patients (8,078 patients were assessed at 1-year, 702 patients at 2-year, and 4,172 patients at 5-year) undergoing primary TKA were enrolled by 230 surgeons in 28 states between 2012–2015. Surgeons practices varied in size, reimbursement models, and geographic setting ensuring that the cohort included diverse patient populations and delivery models. Surgeons agreed to invite all TKA patients to participate and sporadic audits of surgical logs validated that all patients were invited and > 90% of patients were included. Demographic and clinical data [age, gender, body mass index (BMI), and modified Charlson co-morbidity index (CCI)] were collected. Patient-reported outcome measures (PROMs) were collected pre-op and post-op at 1, 2, and 5 years using an internet-based platform including the KOOS (total score, and pain, ADL, QoL sub scores), KOOS Jr, SF-36 (PCS and MCS). We used the single-item satisfaction scale which was tested and validated by the Swedish Knee Arthroplasty Registry. The patients' responses were made on 5-point Likert scale (very satisfied, somewhat satisfied, neutral, somewhat dissatisfied, very dissatisfied). Patients were classified into 2 categories: satisfied group for patients who answered satisfied or very satisfied and dissatisfied group for patients answered neutral, somewhat dissatisfied, or very dissatisfied. Univariate analysis of the difference between the satisfied and dissatisfied patients' groups was performed using Mann-Whitney U test for continuous variables and chi-square test for categorical variables. Logistic regression model was performed to study the correlation between the satisfaction and PROMs with 95% confidence interval. Results. Mean age was 66.6 years, 62.7% were female, and mean BMI was 31.6. The CCI was 0 in 55.1%, 1 in 22%, 2–5 in 12.6% and ≥ 6 in 10.3%. Cumulative revision rate was 1.29% at 2 years. The 30-day adverse events incidence was 2.5% while the 90-day adverse events incidence was 4.7%. The dissatisfaction rate was 18.1% at 1-year, 11.5% at 2-year, and 8.5% at 5-year (P<0.001, Chi-square). Dissatisfaction significantly affects younger patients (<55 years) (P=0.04, Chi-square) and patients with high Charlson comorbidity index >1 (P=0.001, Chi-square). Low post-operative KOOS Pain, KOOS ADL, KOOS total score, KOOS JR, SF-36 PCS, and SP-36 MCS scores were significantly associated with dissatisfaction (P<0.001). At 5 years follow-up, in patients with KOOS scores greater than 70, 1.3% of patients were dissatisfied; with KOOS 50–70, 16.3% were dissatisfied and when KOOS < 50, 62.2% are dissatisfied. Logistic regression showed significant correlation of satisfaction with postoperative KOOS pain, KOOS ADL, KOOS QoL, KOOS total score, KOOS JR, and SF-36 PCS (P< 0.001) at 1-year, 2-year, and at 5-year. The MCS was correlated with patient satisfaction only at 1-year (P< 0.001). Conclusion. The patient dissatisfaction rate 5 years after TKA is 8.1% in FORCE-TJR patients which is significantly lower than 18.1% at 1-year. Less improvement of PROM scores after TKA are significantly associated with patient dissatisfaction. Postoperative PROM scores are associated with patient satisfaction at 1-year, 2-years, and 5-years. When the 5-year post- op KOOS total score is >70, 98.7% of patients are satisfied and only 1.3% are dissatisfied. Patient satisfaction is an important outcome measure after TKA that can be determined by asking a single question. However, in order to understand why a patient is dissatisfied, KOOS scores (KOOS pain, KOOS ADL, KOOS QoL) that assess specific postoperative outcomes can assist in determining the reason for patient dissatisfaction after TKA

Aims. Patient dissatisfaction is not uncommon following primary total knee arthroplasty. One proposed method to alleviate this is by improving knee kinematics. Therefore, we aimed to answer the following research question: are there significant differences in knee kinematics based on the design of the tibial insert (cruciate-retaining (CR), ultra-congruent (UC), or medial congruent (MC))?. Methods. Overall, 15 cadaveric knee joints were examined with a CR implant with three different tibial inserts (CR, UC, and MC) using an established knee joint simulator. The effects on coronal alignment, medial and lateral femoral roll back, femorotibial rotation, bony rotations (femur, tibia, and patella), and patellofemoral length ratios were determined. Results. No statistically significant differences were found regarding coronal alignment (p = 0.087 to p = 0.832). The medial congruent insert demonstrated restricted femoral roll back (mean medial 37.57 mm; lateral 36.34 mm), while the CR insert demonstrated the greatest roll back (medial 42.21 mm; lateral 37.88 mm; p < 0.001, respectively). Femorotibial rotation was greatest with the CR insert with 2.45° (SD 4.75°), then the UC insert with 1.31° (SD 4.15°; p < 0.001), and lowest with the medial congruent insert with 0.8° (SD 4.24°; p < 0.001). The most pronounced patella shift, but lowest patellar rotation, was noted with the CR insert. Conclusion. The MC insert demonstrated the highest level of constraint of these inserts. Femoral roll back, femorotibial rotation, and single bony rotations were lowest with the MC insert. The patella showed less shifting with the MC insert, but there was significantly increased rotation. While the medial congruent insert was found to have highest constraint, it remains uncertain if this implant recreates native knee kinematics or if this will result in improved patient satisfaction. Cite this article: Bone Jt Open 2024;5(7):592–600

Aims. Social media is a popular resource for patients seeking medical information and sharing experiences. periacetabular osteotomy (PAO) is the gold-standard treatment for symptomatic acetabular dysplasia with good long-term outcomes. However, little is known regarding the perceived outcomes of PAO on social media. The aims of this study were to describe the perceived outcomes following PAO using three social media platforms: Facebook, Instagram, and X (formerly known as Twitter). Methods. Facebook, Instagram, and X posts were retrospectively collected from 1 February 2023. Facebook posts were collected from the two most populated interest groups: “periacetabular osteotomy” and “PAO Australia.” Instagram and X posts were queried using the most popular hashtags: #PAOwarrior, #periacetabularosteotomy, #periacetabularosteotomyrecovery, #PAOsurgery, and #PAOrecovery. Posts were assessed for demographic data (sex, race, location), perspective (patient, physician, professional organization, industry), timing (preoperative vs postoperative), and perceived outcome (positive, negative, neutral). Results. A total of 1,054 Facebook posts, 1,003 Instagram posts, and 502 X posts were consecutively assessed from 887 unique authors. The majority (63.3%) of these posts were from patients in the postoperative period, with a median of 84 days postoperatively (interquartile range 20 to 275). The longest follow-up timeframe postoperatively was 20 years. Regarding perceived outcomes, 52.8% expressed satisfaction, 39.7% held neutral opinions, and 7.5% were dissatisfied. Most dissatisfied patients (50.9%) reported pain (chronic or uncontrolled acute) as an attributing factor. Conclusion. Most PAO-perceived surgical outcomes on social media had a positive tone. Findings also indicate that a small percentage of patients reported negative perceived outcomes. However, dissatisfaction with PAO primarily stemmed from postoperative pain. Social media posts from other sources (physicians, hospitals, professional organizations, etc.) trend towards neutrality. Healthcare providers must consider the social media narratives of patients following PAO, as they may reveal additional outcome expectations and help improve patient-centred care, create informed decision-making, and optimize treatment outcomes. Cite this article: Bone Jt Open 2024;5(1):53–59

Introduction and Objective. TKA have shown both excellent long-term survival rate and symptoms and knee function improvement. Despite the good results, the literature reports dissatisfaction rates around 20%. This rate of dissatisfaction could be due to the overstuff that mechanically aligned prostheses could produce during the range of motion. Either size discrepancy between bone resection and prosthetic component and constitutional mechanical tibiofemoral alignment (MTFA) alteration might increase soft tissue tension within the joint, inducing pain and functional limitation. Materials and Methods. Total knee arthroplasties performed between July 2019 and September 2020 were examined and then divided into two groups based on the presence (Group A) or absence (Group B) of patellofemoral overstuff, defined as a thickness difference of more than 2 mm between chosen component and bone resection performed, taking into account at least one of the following: femoral medial and lateral condyle, medial or lateral trochlea and patella. Based on pre and post-operative MTFA measurements, Group A was further divided into two subgroups whether the considered alignment was modified or not. Patients were assessed pre-operatively and at 6 months post-op using the Knee Society Score (KSS), Oxford Knee Score (OKS), Forgotten Joint Score (FJS), Visual Analogue Scale (VAS) and Range of Motion (ROM). Results. One hundred total knee arthroplasties were included in the present study, 69 in Group A and 31 in group B. Mean age and BMI of patients was respectively 71 and 29.2. The greatest percentage of Patellofemoral Overstuff was found at the distal lateral femoral condyle. OKS, KSS functional score, and FJS were statistically significant higher in patients without Patellofemoral Overstuff. Therefore, Group A patients with a non-modified MTFA demonstrated statistically significant better KSS, ROM and FJS. Conclusions. Patellofemoral Overstuff decrease post-operative clinical scores in patients treated with TKA. The conventional mechanically aligned positioning of TKA components might be the primary cause of prosthetic overstuffing leading to worsened clinical results. Level of evidence: III; Prospective Cohort Observational study;

Aims. This study assesses patient barriers to successful telemedicine care in orthopaedic practices in a large academic practice in the COVID-19 era. Methods. In all, 381 patients scheduled for telemedicine visits with three orthopaedic surgeons in a large academic practice from 1 April 2020 to 12 June 2020 were asked to participate in a telephone survey using a standardized Institutional Review Board-approved script. An unsuccessful telemedicine visit was defined as patient-reported difficulty of use or reported dissatisfaction with teleconferencing. Patient barriers were defined as explicitly reported barriers of unsatisfactory visit using a process-based satisfaction metric. Statistical analyses were conducted using analysis of variances (ANOVAs), ranked ANOVAs, post-hoc pairwise testing, and chi-squared independent analysis with 95% confidence interval. Results. The survey response rate was 39.9% (n = 152). The mean age of patients was 51.1 years (17 to 85), and 55 patients (38%) were male. Of 146 respondents with completion of survey, 27 (18.5%) reported a barrier to completing their telemedicine visit. The majority of patients were satisfied with using telemedicine for their orthopaedic appointment (88.8%), and found the experience to be easy (86.6%). Patient-reported barriers included lack of proper equipment/internet connection (n = 13; 8.6%), scheduling difficulty (n = 2; 1.3%), difficulty following directions (n = 10; 6.6%), and patient-reported discomfort (n = 2; 1.3%). Barriers based on patient characteristics were age > 61 years, non-English primary language, inexperience with video conferencing, and unwillingness to try telemedicine prior to COVID-19. Conclusion. The barriers identified in this study could be used to screen patients who would potentially have an unsuccessful telemedicine visit, allowing practices to provide assistance to patients to reduce the risk of an unsuccessful visit. Cite this article: Bone Jt Open 2021;2(9):745–751

Total Knee Arthroplasty (TKA) is a successful treatment for end stage osteoarthritis of the knee joint. However, post-operative pain can lead to patient dissatisfaction and poorer outcomes. Cooled radiofrequency nerve ablation (CRNA) has reportedly been effective at treating pain osteoarthritic knee pain by targeting the periarticular nerves of the knee. We undertook a prospective, controlled pilot study to determine if CRNA provides effective post-operative analgesia when utilised intra-operatively during total knee arthroplasty. Participants were recruited from January 2019 to February 2020. Those meeting inclusion criteria underwent TKA with intraoperative CRNA to 6 target sites prior to the cementing of implants. The primary outcomes were pain scores and opiate usage in the first 4 days post-operatively, then weekly up to 6 weeks. A total of 62 patients were screened and allocated sequentially; 18 were recruited to the control group and 12 recruited to the study group. The two groups did not have any significant difference in demographics. There were no clinically significant differences between the two groups in terms of pain scores nor opiate usage. There were complications as a result of the intervention. This study demonstrated no benefit of using intraoperative CRNA for improving post-operative pain scores or reducing opiate use after TKA

Aims. Metal allergy in knee arthroplasty patients is a controversial topic. We aimed to conduct a scoping review to clarify the management of metal allergy in primary and revision total knee arthroplasty (TKA). Methods. Studies were identified by searching electronic databases: Cochrane Central Register of Controlled Trials, Ovid MEDLINE, and Embase, from their inception to November 2020, for studies evaluating TKA patients with metal hypersensitivity/allergy. All studies reporting on diagnosing or managing metal hypersensitivity in TKA were included. Data were extracted and summarized based on study design, study population, interventions and outcomes. A practical guide is then formulated based on the available evidence. Results. We included 38 heterogeneous studies (two randomized controlled trials, six comparative studies, 19 case series, and 11 case reports). The evidence indicates that metal hypersensitivity is a rare complication with some histopathological features leading to pain and dissatisfaction with no reliable screening tests preoperatively. Hypoallergenic implants are viable alternatives for patients with self-reported/confirmed metal hypersensitivity if declared preoperatively; however, concerns remain over their long-term outcomes with ceramic implants outperforming titanium nitride-coated implants and informed consent is paramount. For patients presenting with painful TKA, metal hypersensitivity is a diagnosis of exclusion where patch skin testing, lymphocyte transformation test, and synovial biopsies are useful adjuncts before revision surgery is undertaken to hypoallergenic implants with shared decision-making and informed consent. Conclusion. Using the limited available evidence in the literature, we provide a practical approach to metal hypersensitivity in TKA patients. Future national/registry-based studies are needed to identify the scale of metal hypersensitivity, agreed diagnostic criteria, and management strategies. Cite this article: Bone Jt Open 2021;2(10):785–795

Aims. The aim of this study was to identify factors associated with poor outcome following coccygectomy on patients with chronic coccydynia and instability of the coccyx. Methods. From the Danish National Spine Registry, DaneSpine, 134 consecutive patients were identified from a single centre who had coccygectomy from 2011 to 2019. Patient demographic data and patient-reported outcomes, including pain measured on a visual analogue scale (VAS), Oswestry Disability Index (ODI), EuroQol five-dimension five-level questionnaire, and 36-Item Short-Form Health Survey questionnaire (SF-36) were obtained at baseline and at one-year follow-up. Patient satisfaction was obtained at follow-up. Regression analysis, including age, sex, smoking status, BMI, duration of symptoms, work status, welfare payment, preoperative VAS, ODI, and SF-36 was performed to identify factors associated with dissatisfaction with results at one-year follow-up. Results. A minimum of one year follow-up was available in 112 patients (84%). Mean age was 41.9 years (15 to 78) and 97 of the patients were female (87%). Regression showed no statistically significant association between the investigated prognostic factors and a poor outcome following coccygectomy. The satisfied group showed a statistically significant improvement in patient-reported outcomes at one-year follow-up from baseline, whereas the dissatisfied group did not show a significant improvement. Conclusion. We did not identify factors associated with poor outcome following coccygectomy. This suggests that neither of the included parameters should be considered contraindications for coccygectomy in patients with chronic coccydynia and instability of the coccyx. Cite this article: Bone Jt Open 2021;2(7):540–544

Aims. This study aims to describe the pre- and postoperative self-reported health and quality of life from a national cohort of patients undergoing elective total conventional hip arthroplasty (THA) and total knee arthroplasty (TKA) in Australia. For context, these data will be compared with patient-reported outcome measures (PROMs) data from other international nation-wide registries. Methods. Between 2018 to 2020, and nested within a nationwide arthroplasty registry, preoperative and six-month postoperative PROMs were electronically collected from patients before and after elective THA and TKA. There were 5,228 THA and 8,299 TKA preoperative procedures as well as 3,215 THA and 4,982 TKA postoperative procedures available for analysis. Validated PROMs included the EuroQol five-dimension five-level questionnaire (EQ-5D-5L; range 0 to 100; scored worst-best health), Oxford Hip/Knee Scores (OHS/OKS; range 0 to 48; scored worst-best hip/knee function) and the 12-item Hip/Knee disability and Osteoarthritis Outcome Score (HOOS-12/KOOS-12; range 0 to 100; scored best-worst hip/knee health). Additional items included preoperative expectations, patient-perceived improvement, and postoperative satisfaction. Descriptive analyses were undertaken. Results. For THA and TKA patients respectively, the patient profile was 2,850 (54.5%) and 4,684 (56.4%) female, mean age 66.8 years (SD 10.6) and 67.5 (SD 8.8), and mean BMI 29.9 kg/m. 2. (SD 7.7) and 32.5 kg/m. 2. (SD 7.0). The proportion of THA and TKA patients who reported their joint as ‘much better’ was 2,946 (92.6%) and 4,020 (81.6%) respectively, and the majority of patients were ‘satisfied’ or ‘very satisfied’ with their procedure (2,754 (86.5%) and 3,981 (80.8%)). There were 311 (9.7%) of THA patients and 516 (10.5%) of TKA patients who reported ‘dissatisfied’ or ‘very dissatisfied’ with their surgery. Conclusion. Large improvements in pain, function, and overall health were evident following primary THA and TKA. Approximately 10% of patients reported dissatisfaction with their surgery. Future analyses will focus on factors contributing to dissatisfaction after arthroplasty. Cite this article: Bone Jt Open 2021;2(6):422–432

Abstract. Introduction. There is little published literature to support the claim that a successful total knee replacement (TKR) is predictive of future good outcomes on the contralateral side. The objective was to identify whether outcome from the first of staged TKRs could be used to predict the outcome of the contralateral TKR. Methodology. This was a retrospective cohort study of 1687 patients over a 25-year period undergoing staged bilateral TKRs in a UK arthroplasty centre. A control group of 1687 patients undergoing unilateral TKR with matched characteristics was identified. Primary outcomes: satisfaction and Knee Society Score (KSS) at one year. Results. Preoperative status was comparable for pain, ROM and KSS (mean 41, 45, 43±14). At one year, dissatisfaction was similar for all groups (4% first of staged TKR, 4% second of staged TKR, 5% controls). If the first TKR had a good outcome, the relative risk of a contralateral bad outcome was 20% less than controls (95% CI 0.6–1.2). If the first TKR had a poor outcome, the risk of a second poor outcome was 4 times higher (95% CI 2.8–6.1), increasing from 6% to 28% (absolute risk). Conclusion. Patients undergoing the second of staged TKRs with a previous good outcome are likely to do well in their second procedure (94 in 100 will go on to have a second good outcome). Of those with a previous poor outcome, 28 in 100 will have a second poor outcome. The trend was persistent despite correcting for gender, age, BMI, and diagnosis

There is little published literature to support the claim that a successful total knee replacement (TKR) is predictive of future good outcomes on the contralateral side. The objective was to identify whether outcome from the first of staged TKRs could be used to predict the outcome of the contralateral TKR. This was a retrospective cohort study of 1687 patients over a 25-year period undergoing staged bilateral TKRs in a UK arthroplasty centre. A control group of 1687 patients undergoing unilateral TKR with matched characteristics was identified. Primary outcomes were satisfaction and Knee Society Score (KSS) at one year. Preoperative status was comparable for pain, ROM and KSS (mean 41, 45, 43±14). At one year follow up, dissatisfaction was similar for all groups (4% first of staged TKR, 4% second of staged TKR, 5% controls). If the first TKR had a good outcome, the relative risk of a contralateral bad outcome was 20% less than controls (95% CI 0.6–1.2). If the first TKR had a poor outcome, the risk of a second poor outcome was 4 times higher (95% CI 2.8–6.1), increasing from 6% to 27% (absolute risk). Patients undergoing the second of staged TKRs with a previous good outcome are likely to do well in their second procedure (94 in 100 will go on to have a second good outcome). Of those with a previous poor outcome, 27 in 100 will have a second poor outcome. The trend was persistent despite correcting for gender, age, BMI, and diagnosis