Abstract. Introduction. Anxiety and depression are risk factors for poor outcome following knee replacement surgery. The aim of this study was to investigate the prevalence of anxiety and depression before and after primary (pKR) and revision knee replacement (rKR). Methodology. Retrospective cohort study. 315,720 pKR and 12,727 rKR recruited from the NHS Patient Reported Outcome Measures (PROMs) programme from 2013–2021. Anxiety and depression were defined using: (i) Survey question: “Have you been told by a doctor that you have depression? Yes/No”; (ii) EQ-5D anxiety/depression domain. Rates of EQ-5D anxiety/depression were investigated at baseline and at 6-months following surgery. The prevalence of depression was investigated by patient age and gender. Results. Overall, 28,434/315,720 (9.0%) pKR and 1,536/12,727 (12.0%) rKR reported pre-operative depression. For all age groups, depression was more common in female than male patients. Prevalence of depression reduced with age (<60 years: 16.8% pKR, 22.7% rKR; 80+ years: 5.3% pKR, 5.2% rKR). Depression was most prevalent in female patients, under 60 years undergoing rKR (25.6%). Pre-operation, 109,000/303,998 (35.9%) pKR and 5,433/12,216 rKR (44.5%) reported moderate or extreme EQ-5D anxiety/depression. Post-operation, 65,351/308,914 (21.2%) pKR and 4,176/12,409 rKR (33.7%) reported moderate or extreme EQ-5D anxiety/depression. Conclusion. Anxiety and depression were prevalent in patients undergoing knee replacement surgery. Patients undergoing revision procedures, female patients and younger patients had the highest rates of depression. Large improvements in anxiety/depression were observed at early follow-up after pKR and rKR

Introduction. Patients undergoing TJA have higher rates of anxiety and/or depression than the general population and higher costs of care. These preoperative diagnoses lead to higher levels of postoperative dissatisfaction and depression patients alone have higher readmission rates. There is significant crossover between anxiety and depressive disorders, and many patients are classed as combined. Our goal was to evaluate readmission rates of patients undergoing total hip or knee arthroplasty with diagnoses of anxiety, depression or both. Methods. Our hospital's prospectively collected data from our statewide total joint database (MARCQI) was reviewed from 2013–2018. Rates of anxiety and/or depression were determined based preoperative anxiolytic or antidepressant medications using national drug codes. Independent sample t-tests compared continuous variables and Chi-square tests (or Fisher's exact tests) compared categorical variables. Potential risk factors were identified by multivariable logistic regression modeling. Results. 4,107 cases (1,261 THA and 2,846 TKA) were included. 176 patients (4.28%) had a readmission within the 90-day global period. 476 patients (12%) had history of depression or anxiety or both. For the entire cohort, those on anxiolytic medication were 153% more likely to be readmitted than those not on medication (p=0.017). When patients were stratified based on THA or TKA, patients taking anxiolytic medication undergoing TKA were 120% more likely to undergo readmission within 90 days (p=0.021). Patients on depression medication alone were not at increased risk of readmission in the TKA cohort (p=0.991). For THA patients neither diagnosis appeared a risk factor for readmission (p=0.852). Conclusions. Patients with depression, anxiety, or both undergoing TKA were at a statistically significant risk of readmission within 90-days compared to patients without these diagnoses. Anxiety and depression were both risk factors for readmission, but anxiety appeared to have a more significant impact. THA on the other hand did not appear to share this risk profile

Aims. Despite new technologies for total knee arthroplasty (TKA), approximately 20% of patients are dissatisfied. A major reason for dissatisfaction and revision surgery after TKA is persistent pain. The radiological grade of osteoarthritis (OA) preoperatively has been investigated as a predictor of the outcome after TKA, with conflicting results. The aim of this study was to determine if there is a difference in the intensity of pain 12 months after TKA in relation to the preoperative radiological grade of OA alone, and the combination of the intensity of preoperative pain and radiological grade of OA. Methods. The preoperative data of 300 patients who underwent primary TKA were collected, including clinical information (age, sex, preoperative pain), psychological variables (depression, anxiety, pain catastrophizing, anticipated pain), and quantitative sensory testing (temporal summation, pressure pain thresholds, conditioned pain modulation). The preoperative radiological severity of OA was graded according to the Kellgren-Lawrence (KL) classification. Persistent pain in the knee was recorded 12 months postoperatively. Generalized linear models explored differences in postoperative pain according to the KL grade, and combined preoperative pain and KL grade. Relative risk models explored which preoperative variables were associated with the high preoperative pain/low KL grade group. Results. Pain 12 months after TKA was not associated with the preoperative KL grade alone. Significantly increased pain 12 months after TKA was found in patients with a combination of high preoperative pain and a low KL grade (p = 0.012). Patients in this group were significantly more likely to be male, younger, and have higher preoperative pain catastrophizing, higher depression, and lower anxiety (all p ≤ 0.05). Conclusion. Combined high preoperative pain and low radiological grade of OA, but not the radiological grade alone, was associated with a higher intensity of pain 12 months after primary TKA. This group may have a more complex cause of pain that requires additional psychological interventions in order to optimize the outcome of TKA. Cite this article: Bone Joint J 2022;104-B(11):1202–1208

Purpose. Patient expectations of total knee arthroplasty (TKA) can be managed through education. E-learning is the application of information technology to education. Providing information to patients at the place and time of their choosing, e-learning has the potential to broaden the reach of existing services for patients. This study evaluated whether an e-learning tool could affect whether patients felt their expectations were met and whether they were satisfied with surgery one year following primary TKA. Method. We recruited consecutive patients with osteoarthritis and randomized them to either standard patient education (n=207), or to our standard patient education plus a new e-learning tool (n=209). Preoperative measures were completed following the patients’ Pre-Admission clinic (PAC) visit and prior to accessing the e-learning tool. Postoperative patient reported outcome measures (PROMs) were completed at six weeks, three months and one year after TKA. We used the Postoperative Expectation Questionnaire to measure the degree to which patient expectations had been met and the Patient Acceptable Symptom State (PASS) question to measure patient satisfaction at one year postoperative. We collected several PROMs for descriptive purposes including: new Knee Society Knee Scoring System (KSS); (Pre-Op and Post-Op versions), Knee injury and Osteoarthritis Outcome Score (KOOS), the Medical Outcomes Study 12-Item Short Form Health Survey, version 2 (SF-12), Hospital Anxiety and Depression Scale (HADS), Pain Catastrophizing Scale (PCS), University of California at Los Angeles (UCLA) Activity Score, and the Social Role Participation Questionnaire (SRPQ). Results. Both groups were similar with respect to their preoperative PROMs. Preoperative patient satisfaction was low, with few patients satisfied with their present state prior to TKA and similar between groups (14% intervention group, 11% control group). At one year postoperatively, the risk that expectations of patients were not met was 21.8% in the control group and 21.4% in the intervention group for a risk difference of 1.3% (95% CI −7.8% to 10.4%, p = 0.78). The proportion of patients satisfied with their TKA at one year postoperative was similar in the intervention group 78.6% and the control group 78.2%, and the risk difference 0.6% (95% CI −8.4% to 9.6%) was not statistically significant (p = 0.78). At one year postoperative we found significant postoperative between-group differences in favour of the control group for the new KSS symptoms score and the functional activities score. We also found that control patients had less anxiety, lower scores for rumination, magnification, and helplessness than intervention patients on the PCS. Conclusion. Patients randomized to the e-learning tool had significantly better KSS symptom scores and functional activities scores as well as lower anxiety and helplessness scores but they did not have a reduced risk of expectations not being met or an improved overall satisfaction with their TKA

This cohort study investigated the influence of psychological factors, including perception of illness, anxiety and depression on recovery and functional outcome after total knee replacement surgery. . A total of 100 patients (55 male; 45 female) with a mean age of 71 (42 to 92) who underwent a primary total knee replacement for osteoarthritis were recruited into this study. In all 97 participants completed the six week and 87 the one year follow-up questionnaires. . Pre-operatively patients completed the revised Illness Perception Questionnaire, Hospital Anxiety and Depression Scale and Recovery Locus of Control Scale. Function was assessed pre-operatively, at six weeks and one year using Oxford Knee Score (OKS) and the goniometer-measured range of movement (ROM). . The results showed that pre-operative function had the biggest impact on post-operative outcome for ROM and OKS. In addition questionnaire variables and depression had an impact on the OKS at six weeks. Depression and anxiety were also associated with a higher (worse) knee score at one year but did not influence the ROM at either six weeks or one year. Recovery from total knee replacement can be difficult to predict. This study has identified psychological factors that play an important role in recovery from surgery and functional outcome. These should be taken into account when considering patients for total knee replacement. Cite this article: Bone Joint J 2014;96-B:210–16

Aims. The primary aim of this study was to determine the surgical team’s learning curve for introducing robotic-arm assisted unicompartmental knee arthroplasty (UKA) into routine surgical practice. The secondary objective was to compare accuracy of implant positioning in conventional jig-based UKA versus robotic-arm assisted UKA. Patients and Methods. This prospective single-surgeon cohort study included 60 consecutive conventional jig-based UKAs compared with 60 consecutive robotic-arm assisted UKAs for medial compartment knee osteoarthritis. Patients undergoing conventional UKA and robotic-arm assisted UKA were well-matched for baseline characteristics including a mean age of 65.5 years (. sd. 6.8) vs 64.1 years (. sd. 8.7), (p = 0.31); a mean body mass index of 27.2 kg.m2 (. sd. 2.7) vs 28.1 kg.m2 (. sd. 4.5), (p = 0.25); and gender (27 males: 33 females vs 26 males: 34 females, p = 0.85). Surrogate measures of the learning curve were prospectively collected. These included operative times, the Spielberger State-Trait Anxiety Inventory (STAI) questionnaire to assess preoperative stress levels amongst the surgical team, accuracy of implant positioning, limb alignment, and postoperative complications. Results. Robotic-arm assisted UKA was associated with a learning curve of six cases for operating time (p < 0.001) and surgical team confidence levels (p < 0.001). Cumulative robotic experience did not affect accuracy of implant positioning (p = 0.52), posterior condylar offset ratio (p = 0.71), posterior tibial slope (p = 0.68), native joint line preservation (p = 0.55), and postoperative limb alignment (p = 0.65). Robotic-arm assisted UKA improved accuracy of femoral (p < 0.001) and tibial (p < 0.001) implant positioning with no additional risk of postoperative complications compared to conventional jig-based UKA. Conclusion. Robotic-arm assisted UKA was associated with a learning curve of six cases for operating time and surgical team confidence levels but no learning curve for accuracy of implant positioning. Cite this article: Bone Joint J 2018;100-B:1033–42

Aims. The purpose of this study was to evaluate trends in opioid use after unicompartmental knee arthroplasty (UKA), to identify predictors of prolonged use and to compare the rates of opioid use after UKA, total knee arthroplasty (TKA) and total hip arthroplasty (THA). Materials and Methods. We identified 4205 patients who had undergone UKA between 2007 and 2015 from the Humana Inc. administrative claims database. Post-operative opioid use for one year post-operatively was assessed using the rates of monthly repeat prescription. These were then compared between patients with and without a specific variable of interest and with those of patients who had undergone TKA and THA. Results. A total of 4205 UKA patients were analysed. Of these, 1362 patients (32.4%) were users of opioids. Pre-operative opioid use was the strongest predictor of prolonged opioid use after UKA. Opioid users were 1.4 (81.6% versus 57.7%), 3.7 (49.5% versus 13.3%) and 5.5 (35.8% versus 6.5%) times more likely to be taking opioids at one, two and three months post-operatively, respectively (p < 0.05 for all). Younger age and specific comorbidities such as anxiety/depression, smoking, back pain and substance abuse were found to significantly increase the rate of repeat prescription for opioids after UKA. Overall, UKA patients required significantly less opioid prescriptions than patients who had undergone THA and TKA. Conclusion. One-third of patients who undergo UKA are given opioids in the three months pre-operatively. Pre-operative opioid use is the best predictor of increased repeat prescriptions after UKA. However, other intrinsic patient characteristics are also predictive. Cite this article: Bone Joint J 2018;100-B(1 Supple A):62–7

We identified a group of patients from the Swedish Arthroplasty Register who reported no relief of pain or worse pain one year after a total knee replacement (TKR). A total of two different patient-reported pain scores were used during this process. We then evaluated how the instruments used to measure pain affected the number of patients who reported no relief of pain or worse pain, and the relative effect of potential risk factors. . Between 2008 and 2010, 2883 TKRs were performed for osteoarthritis in two Swedish arthroplasty units. After applying exclusion criteria, 2123 primary TKRs (2123 patients) were included in the study. The Knee injury and Osteoarthritis Outcome Score (KOOS) and a Visual Analogue Scale (VAS) for knee pain were used to assess patients pre-operatively and one year post-operatively. . Only 50 of the 220 patients (23%) who reported no pain relief on either the KOOS pain subscale or the VAS for knee pain did so with both of these instruments. Patients who reported no pain relief on either measure tended to have less pain pre-operatively but a higher degree of anxiety. Charnley category C was a predictor for not gaining pain relief as measured on a VAS for knee pain. . The number of patients who are not relieved of pain after a TKR differs considerably depending on the instrument used to measure pain. . Cite this article: Bone Joint J 2014;96-B:1222–6

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To map literature on prognostic factors related to outcomes of revision total knee arthroplasty (rTKA), to identify extensively studied factors and to guide future research into what domains need further exploration.

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This study investigated the effects of transcatheter arterial embolization (TAE) on pain, function, and quality of life in people with early-stage symptomatic knee osteoarthritis (OA) compared to a sham procedure.

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The aim of this study was to describe and compare joint-specific and generic health-related quality of life outcomes of the first versus second knee in patients undergoing staged bilateral total knee arthroplasty (BTKA) for osteoarthritis.

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This study investigates whether primary knee arthroplasty (KA) restores health-related quality of life (HRQoL) to levels expected in the general population.

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The aim of this study was to report the meaningful values of the EuroQol five-dimension three-level questionnaire (EQ-5D-3L) and EuroQol visual analogue scale (EQ-VAS) in patients undergoing primary knee arthroplasty (KA).

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In cases of severe periprosthetic joint infection (PJI) of the knee, salvage procedures such as knee arthrodesis (KA) or above-knee amputation (AKA) must be considered. As both treatments result in limitations in quality of life (QoL), we aimed to compare outcomes and factors influencing complication rates, mortality, and mobility.

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The aim of this study was to evaluate the cost-effectiveness of arthroscopic partial meniscectomy versus physical therapy plus optional delayed arthroscopic partial meniscectomy in young patients aged under 45 years with traumatic meniscal tears.

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The rate of day-case total knee arthroplasty (TKA) in the UK is currently approximately 0.5%. Reducing length of stay allows orthopaedic providers to improve efficiency, increase operative throughput, and tackle the rising demand for joint arthroplasty surgery and the COVID-19-related backlog. Here, we report safe delivery of day-case TKA in an NHS trust via inpatient wards with no additional resources.

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The aim of this study was to describe the prevalence and patterns of neuropathic pain over one year in a cohort of patients with chronic post-surgical pain at three months following total knee arthroplasty (TKA).

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To perform an incremental cost-utility analysis and assess the impact of differential costs and case volume on the cost-effectiveness of robotic arm-assisted unicompartmental knee arthroplasty (rUKA) compared to manual (mUKA).

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The aim of this study was to estimate the incremental use of resources, costs, and quality of life outcomes associated with surgical reconstruction compared to rehabilitation for long-standing anterior cruciate ligament (ACL) injury in the NHS, and to estimate its cost-effectiveness.

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The aims of this study were to assess mapping models to predict the three-level version of EuroQoL five-dimension utility index (EQ-5D-3L) from the Oxford Knee Score (OKS) and validate these before and after total knee arthroplasty (TKA).