Quality of life post total knee arthroplasty: Saudi Arabian experience.

Background and Objective: Osteoarthritis of knee is quite common in Saudi Arabian population. Total knee arthroplasty (TKA) was reluctantly accepted in Saudi Arabia about 2 decades ago but there are few small number reports on quality of life (QOL) postsurgery. The objective of this study was to investigate the QOL and overall satisfaction postTKA.
Methods: We retrospectively studied 200 patients' consecutive patients who underwent primary TKA at King Fahd Hospital of the University, AlKhobar, Saudi Arabia. Patient's age, sex, weight, height, body mass index, and range of movements at the time of surgery were extracted from the QuadraMED patients Database. The minimum follow-up was 24 months. At the last visit of 24 months, patients were evaluated using modified Western Ontario and McMaster Universities Osteoarthritis Index (MWOMAC), QOL using Short Form-36 Health Survey (SF-36), and patient satisfaction was assessed.
Results: Among the 212 TKAs performed, 52 were male and 148 were female. One hundred and twenty two were right side and 90 were left side and 22 were bilateral. The mean age was 62.7 ± 5.1 years. There were no intraoperative complications. Nearly 95% resulted in patient satisfaction. SF-36 and all the parameters assessed significantly improved (P < 0.001). MWOMAC scores of the patients, which show all functions, had statistically significantly improved to (P < 0.001) except prayers before and after surgery did not change which was expected. The overall level of satisfaction was observed 95% of patients. Conclusions: Our study shows that TKA has a positive effect on pain, mobility, QOL, and ultimate satisfaction.

INTRODUCTION

Osteoarthritis of knee (OAK) is mostly due to aging process and is suggested that many factors influence the severity of the disease. The prevalence of OAK of the knee is unknown, but recently, it was reported that over 12.5% of the population worldwide over 45 years of age suffer from OAK.[1] The incidence of OAK in Saudi Arabian population was found to be up to 3.5%,[23] but recent reports indicate the prevalence of clinical OAK increased many folds to 13%[4] and radiological OA of the knee to 53% in males and 60.9% in females.[5] Even though the prevalence has increased but there are no new treatments have been added apart from NSAIDs and physical therapy, even though the OAK progresses slowly till the joint is destroyed and quality of life is severely affected.[6] Many patients do not respond to the conservative therapies and require steroid and hyaluronic acid injections, arthroscopic joint washout with varying degrees of pain relief. Total knee arthroplasty (TKA) surgery is most commonly done in people with advanced osteoarthritis where conservative approaches have failed.[7] TKA relieves pain and improves mobility, and in 1990s results reporting good outcome was 90% of patients.[8] Despite good to excellent results, this sort of replacement was a low acceptance in Saudi Arabia due to prayer limitations with TKA. Behairy et al.[9] noted that the acceptance rate for TKA was only 33%.[9] In the past two decades, opinions have changed and many patients have accepted TKA. With this sudden increase in the TKAs in Saudi Arabia, there are few published reports, which indicate functional outcome and satisfaction of TKAs.

The objectives of this study were to evaluate outcomes of quality of life (QOL) and overall satisfaction post-TKA from a University Hospital.

METHODS

We retrospectively studied 200 consecutive patients who underwent primary TKA at King Fahd Hospital of the University, AlKhobar, Saudi Arabia, who were operated by three surgeons including the author. Two different implants manufactured by Biomet and Zimmer were used. The Institutional Review Board of the Imam AbdulRahman Bin Faisal University, Dammam, approved the study. Patient's age, sex, weight, height, body mass index, and range of movements at the time of surgery was extracted from the Quadrumed patients Database. The inclusion criteria were patients who underwent primary TKA who did not have any functional limitations from other diseases and a minimal follow-up for 24 months. The exclusion criteria were those who were operated other than degenerative OA and those having a revision TRA for any cause. QOL was evaluated. The QOL was evaluated based on modified Western Ontario and McMaster Universities Osteoarthritis Index (MWOMAC), Short Form-36 Health Survey (SF-36), and overall satisfaction based on five levels.

All statistical analyses were performed using SPSS Inc. Statistics for MacBook Pro, Version 23 (Chicago, Illinois, USA). Results were considered statistically significant at P < 0.05.

RESULTS

Among the 212 TKAs performed, 52 were male and 148 were female. One hundred and twenty-two were right side and 90 were left side. The mean age was 62.7 ± 5.1 years. The demographic data are shown in Table 1. There were no intraoperative complications. During the 24 months’ assessment period, five patients had superficial wound infections which recovered with a course of antibiotics. Nearly 91.8% resulted in patient satisfaction. Table 2 shows SF-36 and all the parameters assessed significantly improved (P < 0.001). MWOMAC scores of the patients are shown in Table 3, which shows all functions had statistically significantly improved to (P < 0.001) except prayers before and after surgery did not change which was expected. The overall level of satisfaction was observed >90% of patients [Table 4].

Table 1

Demographic data of all patients

Number of patients	200
Males	52
Females	148
Average age (years)	62.7±5.1
BMI k/m2	29.4±4.3

BMI=Body mass index

Table 2

SF-36 preoperative, 24 months postoperative average of 36 subscales scores

	Mean±SD
	Preoperative	Postoperative (24 months)
PF	29±5.8	81±3.2
BP	45±3.9	84±6.7
GH	38±7.4	79±6.1
SF	54±6.7	88±4.5
RE	47±6.3	81±5.9
MH	70±3.8	87±7.2

PF=Physical functioning, BP=Bodily pain, GH=General health, SF=Social functioning, RE=Role-emotional, MH=Mental health, SD=Standard deviation

Table 3

Modified Western Ontario and Mcmaster Universities Osteoarthritis scores of 212 patients

Symptom	Mean±SD
	Preoperative	Postoperative (24 months)
Pain on activity	55±8.9	18.5±5.2
Night pain	43±7.2	13.7±3.5
Mobility	18.6±4.8	66±3.9
Household work	19.4±7.8	48.3±5.7
Activity outside	33±6.7	64±5.8
Prayer	29±2.6	36.6±7.1

SD=Standard deviation

Table 4

Overall satisfaction

Level of satisfaction	n (%)
Extremely satisfied	100 (47.2)
Very satisfied	52 (24.5)
Satisfied	49 (23.1)
Slightly satisfied	8 (4.2)
Not satisfied	3 (1.4)

DISCUSSION

Our study shows that 95% of our patients who underwent primary TKA for OAK were fully satisfied and all the parameters assessed by MWOMAC, SF-36, and 5 levels of satisfaction, even though many studies did report patients being unhappy with the outcome.[101112] Our results appear better than reported earlier which showed the dissatisfaction of twice that of this study.[1013]

Advance OAK is a degenerative painful disease, which limits the mobility of nearly all patients, and TKA is an ultimate option for relief of pain, mobility, and improved QOL. As benefits outweigh the complications TKAs have become a routine procedure to the extent that by this year in the United States alone about 1.3 million TKAs will be performed.[14] Primary TKA volume increased by 79% in Sweden, 127% in Australia, and 384% in the Kaiser Permanente Joint Replacement Registry.[15] The figures for the Middle East and Saudi Arabia are not yet reported it appears this has increased in the past 10 years and bound to increase as the population is aging.

As TKA volume is increasing it becomes imperative to study patient satisfaction with the procedure. Different outcome scales have been used to measure the efficacy of TKA based on patient's satisfaction. These are either subjective methods dependent on the physicians questioning of the patients on two parameters namely pain and function[10] and second by objective way using WOMAC, Knee Society Score (KSS), or SF-36 scoring systems.[1617] Preoperative expectation is always the basis of patients postoperative satisfaction in any surgery and TKA is no different and studies have shown to this effect with regard to TKA.[181920] In our patients, the expectation was painless mobility and that was provided to them after TKA and hence were satisfied. The smaller group of patients, who did not expect to have complications, was not well satisfied.

The data of TKA in Saudi Arabia are limited so as the satisfaction and QOL postsurgery, this indicates that clinical improvement following TKA is largely understudied. It is critical that more studies and robust data are needed before we can advise the surgeons and patients when such surgery should be performed and in making informed decisions on proceeding with TKA. The study has limitation as it was a retrospective analysis and the numbers are in triple digits and not enough to generalize results for the whole country.

The strength is that TKA is a successful surgery if properly and meticulous done and provides patients with pain and suffering, independent mobility, and improved QOL which all patients deserve. In conclusion, our study shows that patients who have undergone TKAs were quite satisfied with the procedure and outcome in getting relieved of pain and increase in the free mobility. As population in Saudi Arabia is aging and the TKA in future is going to increase hence more studies need to be carried out to prospectively assess the QOL using multiple parameters.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.