Statement of purpose: To evaluate survivorship and knee function in patients who have undergone Kinematic Condylar Total Knee Replacement at a minimum of 15 years.

Methods: We evaluated all patients undergoing primary cemented TKR with the Kinematic Condylar implant (Howmedica), between January 1981 and December 1988. All operations were performed by a single surgeon through a medial parapatellar approach, with sparing of the PCL, all cemented and no patellae resurfaced.

Operation notes were analysed to confirm the type of procedure, underlying diagnosis, and thickness of tibial insert. Information was derived from patient records and postal questionnaire to all surviving patients, which included: WOMAC, SF-36, satisfaction scale and history of revision surgery.

Results: We have identified a total of 804 consecutive cases, 185 of these were bilateral giving a total of 619 patients. Mean age at implantation was 66 (range 17 to 83), with female:male ratio of 3:1. The underlying diagnosis was Osteoarthritis in 49%, and Rheumatoid Arthritis in 51% of patients.

As at September 2003 there were 153 patients (25%) still alive, using revision as an endpoint survivorship was 59.3% at a mean time since implantation of 17 years 8 months. Pain and function portions of the WOMAC questionnaire revealed mean scores of 37 and 47 out of 100.

Conclusion: This cohort has been shown to have 92% implant survivorship at ten years. We have shown that the survivorship deteriorates significantly between 10 and 17 years. Functional and pain scores after 17 years for patients with surviving implants were poor.

Survival was significantly better in females, no effect from pre-operative diagnosis was seen. 73% of these patients had 6mm tibial inserts, we postulate that the deterioration in survival is related to accelerated poly-ethylene wear beyond 10 years.

This study investigates the role of pre-operative mental health on outcome following Total Knee Replacement.

Patients were recruited as part of a prospective, observational study of the outcomes of primary total knee replacement for osteothritis in centres in the United Kingdom (6 centres), United States (4 centres) and Australia (2 centres). Independent, research assistants recruited eligible patients, collecting clinical history and examination data pre-operatively, 3 and 12 month post surgery. The SF-36, WOMAC, patient satisfaction and demographic data were obtained by self-administered questionnaires.

We recruited 862 eligible patients and have completed 12-month data on 742 patients (86%). Mean age was 70 years (SD 10), 59% were female, 50% were from the UK, 30% from the USA and 20% from Australia. In linear regression models, the significant correlates of preoperative mental health (in decreasing order of significance) were: low preoperative WOMAC function (Std B 8, 2; p< 0. 0001), self reported depression (Std 8 7. 6; p< 0, 0001), female gender (Std 13 2. 9 p=0, 004), older age (Std 13 2, 9; p=0. 004), other comorbid conditions (Std 3 2. 8; p=0, 005) and low income (Std B 23; p-0, 03). 12 months following surgery, low pre-operative mental health was a significance predictor of worse WOMAC pain and function (p< 0. 0001). The linear regression models adjusted for preoperative pain and function, age, sex, comorbid conditions, country and centre within country. With the exception of the pre-operative WOMAC pain and function score, low pre-operative mental health was the strongest of worse outcome 12 months after TKR.

Low pre-operative mental health is a highly significant predictor of worse outcome one year after Total Knee Replacement. It may be possible to identify patients with poor mental health before surgery using the SF36 mental health score as well as self-reported depression. This may allow for effective treatment of their mental health problems prior to TKR and/or highlight the need for extra rehabilitation input to improve outcome following surgery.

This study aimed to evaluate the effect of using ICPs (Integrated Care Pathways) on the outcome of TKA.

Prospective data was collected from 429 patients (130 from 2 sites that use 1CPs and 299 from 4 sites that did not). Pre-operatively and at 12 months an independent researcher performed a clinical knee examination and patients completed WOMAC and SF-36 questionnaires. At 12 months patients answered additional questions on satisfaction with outcome. The follow-up rate was 86%.

The median length of stay (LOS) in the ICP group was 9 days compared with 12 in the non-ICP group (p < 0. 001). After adjusting for other significant variables, ICP site was shown to be the most significant factor in shorter LOS (p < 0. 001). Following discharge, 78% of the ICP group and 47% of the non-ICP group received outpatient physiotherapy (p < 0. 001). Logistic regression analysis showed that the ICP group were 4 times more likely to receive outpatient physiotherapy (odds ratio = 4. 35, p < 0. 001). After adjusting for other significant variables and baseline values, at 12 months the ICP group had significantly less pain (p = 0. 041) and significantly better function (p < 0. 00 1) than the non-ICP group. There was no difference in the number of postoperative orthopaedic complications (p = 0. 64). At 12 months, 83% of the ICP group were very satisfied with their surgery compared to 70% of the non-ICP group (p = 0. 009). Logistic regression showed that the ICP group were over twice as likely to be very satisfied with their outcome at 12 months (odds ratio = 2. 27, p = 0. 029).

These results indicate that ICPs can result in shorter LOS without compromising outcome although use of outpatient physiotherapy was increased. In addition ICPs appear to result in greater patient satisfaction.