Quality of life after bilateral total knee arthroplasty determined by a 3-year longitudinal evaluation using the Japanese knee osteoarthritis measure Takehiko Sugita, Yasuhiro Kikuchi, Toshimi Aizawa, Akira Sasaki, Naohisa Miyatake & Ikuo Maeda Journal of Orthopaedic Science Official Journal of the Japanese Orthopaedic Association ISSN 0949-2658 J Orthop Sci DOI 10.1007/s00776-014-0645-9
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Author's personal copy J Orthop Sci DOI 10.1007/s00776-014-0645-9
ORIGINAL ARTICLE
Quality of life after bilateral total knee arthroplasty determined by a 3‑year longitudinal evaluation using the Japanese knee osteoarthritis measure Takehiko Sugita · Yasuhiro Kikuchi · Toshimi Aizawa · Akira Sasaki · Naohisa Miyatake · Ikuo Maeda
Received: 9 April 2014 / Accepted: 24 August 2014 © The Japanese Orthopaedic Association 2014
Abstract Background Recently, the Japanese knee osteoarthritis measure (JKOM), a new disease-specific and patientderived quality of life (QOL) measure, has been developed. The objectives of this study were to longitudinally evaluate QOL assessed by JKOM and objective outcomes including knee society score (KSS), range of motion (ROM), and timed up and go test (TUG) of patients who underwent bilateral total knee arthroplasties (TKAs) for osteoarthritis; to evaluate correlations between JKOM and those objective outcomes; and to test our hypothesis that increased maximum flexion leads to better JKOM. Methods Forty patients with bilateral TKAs and ≥ 3-year follow-up were included. There were 35 female and 5 male patients with a mean patient age of 74 years. They were evaluated preoperatively (Pre), 5–29 months after unilateral TKA (after U), 12–21 months after bilateral TKAs (1 year after B), 24–34 months after bilateral TKAs (2 years after B), and 36–46 months after bilateral TKAs (3 years after B) using JKOM, KSS, TUG, and ROM. Results Improvements in JKOM and TUG were statistically significant between “Pre” and “after U”, and between the “after U” and “1 year after B”. Improvements in the KSS function score were statistically significant between “after U” and “1 year after B” but not between “Pre” and “after U”. The improvements in the JKOM scores, the KSS T. Sugita (*) · Y. Kikuchi · A. Sasaki · N. Miyatake · I. Maeda Department of Orthopaedic Surgery, Tohoku Orthopaedic Clinic, 4‑9‑22 Kamiyagari, Izumi‑ku, Sendai 981‑3121, Japan e-mail: t‑
[email protected] T. Aizawa Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, 1‑1 Seiryo‑machi, Aoba‑ku, Sendai 980‑8574, Japan
function score, and TUG did not increase after the 1-year follow-up but was maintained at “3 years after B”. The maximum flexion value did not change among the evaluation time points. There were statistically significant correlations between JKOM with KSS and TUG but not with ROM. Conclusions There were statistically significant correlations between JKOM with KSS and TUG but not with ROM. Therefore, our hypothesis was false even in a Japanese population.
Introduction Recently, subjective or patient self-reported outcome scales, such as the Western Ontario and McMaster University osteoarthritis index (WOMAC) [1] and medical outcomes study 36-item short-form health survey (SF-36) [2], have been used to assess patients’ quality of life (QOL) after total knee arthroplasty (TKA). Many studies [3–10] have examined the correlation of these subjective outcome scales with objective or physician-driven criteria, such as the knee society score (KSS) [11], range of motion (ROM) of the knee, and timed up and go test (TUG) [12], which had generally been used to assess outcomes. Some of these studies noted that subjective scales were preferable for TKA outcome studies [3, 4, 6, 9]. In Japan, a new diseasespecific and patient-derived QOL measure for Japanese patients with knee osteoarthritis, the Japanese knee osteoarthritis measure (JKOM) [13], was developed to reflect the specifics of the Japanese cultural lifestyle, which is characterized by bending to the floor or standing up. The validity and reliability of JKOM has been examined by comparing it with the widely accepted QOL measures, WOMAC, and SF-36 [13].
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Many patients suffer from bilateral knee pain caused by osteoarthritis. In such patients, the surgical outcomes after bilateral TKAs should be preferable to those after unilateral TKA since the non-operated knee has persistent pain after unilateral TKA, which may deteriorate the QOL of patients. However, to the best of our knowledge, there have been no longitudinal studies to compare the surgical results after unilateral TKA with those after bilateral TKA for patients with osteoarthritis of both knees. Therefore, in the present study, we evaluated patients with bilateral TKAs at the time point after unilateral TKA and bilateral TKA for ≥ 3-year follow-up by both a subjective outcome scale using JKOM and by objective ones using KSS, TUG, and ROM. In addition, as we hypothesized that increased maximum flexion led to better JKOM scores because the Japanese cultural lifestyle occasionally needs high-flexion activities in daily living, we focused on the correlation between JKOM and ROM.
Patients and methods The study protocol was approved by the ethics committee of our clinic. Written informed consent for the use of data in the study was obtained from all patients. Between October 2006 and September 2010, 253 TKAs of 190 patients were done for advanced knee osteoarthritis at our clinic; 63 patients underwent bilateral TKAs. Basically, we scheduled bilateral TKAs for patients suffering from bilateral severe knee osteoarthritis with a 6-month to 1-year interval. Of these 63 patients, 40 had at least 3-year follow-up examinations and were included in this study. Average duration between bilateral TKAs was 9.2 months (range 5–29 months). Simultaneous bilateral TKAs were not performed at our clinic. There were 35 female and 5 male patients with a mean patient age of 74 years (range 63–85 years). Average weight and body mass index of them were 62.2 kg (range 45–93 kg) and 27.4 kg/m2 (range 20.9– 39.7 kg/m2), respectively. The NexGen CR-flex or LPS-flex system (Zimmer, Warsaw, IN, USA) was used for 70 or 10 knees, respectively. Patellae were not resurfaced, and femoral and tibial components were cemented. All TKAs were performed by 3 senior surgeons (TS, AK, and IM), and JKOM, KSS, TUG, and ROM (maximum flexion and flexion contracture) were used to perform the evaluations. Questionnaires included in JKOM and KSS were filled out by the patients themselves in cooperation with physical therapists and objective findings included in KSS, TUG, and ROM were evaluated by physical therapists. The evaluations were performed preoperatively (Pre), 5–29 months after unilateral TKA (after U), 12–21 months after bilateral TKAs (1 year after B), 24–34 months after bilateral TKAs (2 years after B), and 36–46 months after bilateral TKAs
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(3 years after B). JKOM includes 4 domains (25 items): pain and stiffness in knees (8 items), condition in daily life (10 items), general activities (5 items), and health conditions (2 items) (Table 1). Each item has 5 points (1 equals the best function, and 5 equals the worst function). Lower JKOM scores indicate better QOL. The Wilcoxon t-test was used to compare the preoperative and postoperative statuses. Spearman’s nonparametric correlation coefficients were calculated to determine the strengths of correlations between JKOM and objective outcome scales (KSS, TUG, and ROM). p values of < 0.05 were considered statistically significant.
Results Longitudinal changes in JKOM, KSS, TUG, and ROM (maximum flexion and flexion contracture) are summarized in Table 2. Improvements in the JKOM scores were each statistically significant between the “Pre” and “after U” and between the “after U” and “1 year after B” time points (each < 0.01). The improvement did not increase after the 1-year follow-up but was maintained at “3 years after B” (Fig. 1a). Each domain of JKOM showed similar improvement (Fig. 1b). Improvements in the KSS function score were statistically significant between “after U” and “1 year after B” (< 0.01) but not between “Pre” and “after U.” The improvement did not change further but was maintained at the “3 years after B” (Fig. 2). Improvements in TUG were each statistically significant between “Pre” and “after U” (< 0.05) and “after U” and “1 year after B” (< 0.01). The improvements did not increase after the 1-year follow-up but were maintained at “3 years after B” (Fig. 3). Improvements in the KSS score and in flexion contracture were statistically significant between “Pre” and “1 year after B” (< 0.01). The improvement did not change but was maintained at “3 years after B” (Fig. 4a, b). Longitudinal changes in the average maximum flexion of Pre, “1 year after B”, “2 years after B”, and “3 years after B” were 117.9° (range 55–145°), 115.4° (75–135°), 116.5° (75–135°), and 114.9° (75–140°) in the right knee, and 117.4° (70–145°), 114.0° (70–145°), 115.4° (75–140°), and 115.0° (75–130°) in the left knee, respectively (Fig. 5). They did not show any statistically significant changes among the evaluation time points. Because the improvements in the JKOM, KSS, TUG, and ROM scores reached plateaus “1 year after B,” the correlations between JKOM with KSS, TUG, and ROM were evaluated for 40 patients at “1 year after B.” There were statistically significant correlations between JKOM with KSS (< 0.01) and TUG (< 0.01) but not with ROM. The degrees of correlation at “2 years after B” and “3 years after B” were similar. The above correlations are summarized in Table 3.
Author's personal copy Quality of life after TKA Table 1 The content of the Japanese Knee Osteoarthritis Measure (JKOM) I. Degree of knee pain (pain VAS) II. Pain and stiffness in knees Here are a couple of questions regarding your knee function during the last few days. Choose one answer and mark an X in the box next to it. (Options: not at all, slight, moderate, quite, extreme) 1. Do you feel stiffness in your knees when you wake up in the morning? 2. Do you feel pain in your knees when you wake up in the morning? 3. How often do you wake up in the night because of pain in your knees? 4. Do you have pain in your knees when you walk on a flat surface? 5. Do you have pain in your knees when ascending stairs? 6. Do you have pain in your knees when descending stairs? 7. Do you have pain in your knees when bending to the floor or standing up? 8. Do you have pain in your knees when standing? III. Condition in daily life Here are a couple of questions regarding your ability to perform daily routines during the last few days. Choose one answer and mark an X in the box next to it. (Options: not at all, a little, moderately, quite, extremely) 9. How difficult is ascending or descending stairs? 10. How difficult is bending to the floor or standing up? 11. How difficult is standing up from sitting on a western-style toilet? 12. How difficult is wearing pants, skirt, and underwear? 13. How difficult is putting on socks? 14. How long can you walk on a flat surface without taking a rest? (More than 30 min, about 15 min, around my house, can hardly walk) 15. Have you been using a walking stick (cane) recently? (Not at all, hardly, sometimes, often, always) 16. How difficult is shopping for daily necessities? (Not at all, a little, moderately, quite, extremely) 17. How difficult is doing light housework (cleaning the dining room after eating, etc.)? (Not at all, a little, moderately, quite, extremely) 18. How difficult is doing heavy housework (using the vacuum cleaner, etc.)? (Not at all, a little, moderately, quite, extremely) IV. General activities Here are a couple of questions regarding your general activities during the last 1 month. Choose one answer and mark an X in the box next to it 19. Have you gone to an event or to a department store during the last 1 month? (More than 2–3 times a week, about once a week, about every 2 weeks, once a month, not at all) 20. Were things that you usually do (some kind of lesson, meeting friends, etc.) difficult because of knee pain during the last 1 month? (Not at all, a little, moderately, quite, extremely) 21. Did you limit doing things you usually do because of knee pain during the last 1 month? [Not at all, a little, moderately, quite, did not do them (things you do usually) at all] 22. Did you despair of going outside somewhere close because of knee pain during the last 1 month? [Not at all, hardly, sometimes, often, did not go outside (close)] 23. Did you despair of going outside somewhere far because of knee pain during the last 1 month? [Not at all, hardly, sometimes, often, did not go outside (far)] V. Health conditions Here are a couple of questions regarding your health during the last 1 month. Choose one answer and mark an X in the box next to it 24. Do you think your health during the last 1 month has been average? (I really think so, I think so, I do not know, I do not think so, I do not think so at all) 25. Do you think that knee pain has been affecting your health badly during the last 1 month? (It is not affecting it at all, it is affecting it a little, it is affecting it moderately, it is affecting it significantly, it is affecting it greatly)
Discussion Many studies have examined the correlation between objective and subjective outcome scales after TKA [3– 10]. However, longitudinal subjective outcome assessments have been performed in only a few studies [14, 15]. Mizner et al. [14] longitudinally assessed functional
improvement for 100 patients scheduled for unilateral TKA preoperatively and at 1 and 12 months postoperatively. Lozano-Calderon et al. [15] evaluated unilateral TKA patients preoperatively, at 6 weeks, at 3 months, and at 1 and 2 years regarding pain, motion, and function. Both studies evaluated patients with unilateral TKA. To the best of our knowledge, this was the first longitudinal
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Author's personal copy T. Sugita et al. Table 2 Longitudinal changes in JKOM, KSS, TUG, and ROM (average ± standard deviation) Pre JKOM KSS KSS function score TUG Flexion contracture (R)
75.2 ± 15.1 84.6 ± 24.4 46.9 ± 16.7 15.3 ± 9.9
After U
1 year after B
2 years after B
3 years after B
64.6 ± 17.8 (0.0003)
37.0 ± 8.9 (0.0001) 166.7 ± 21.7 (0.0001) 74.1 ± 16.9 (0.0001) 10.1 ± 3.8 (0.0001)
36.5 ± 10.0 (0.507) 168.0 ± 24.8 (0.744) 74.8 ± 20.6 (0.972) 10.0 ± 2.9 (0.681)
36.0 ± 9.2 (0.577) 167.1 ± 20.7 (0.881) 72.3 ± 17.5 (0.328) 10.4 ± 2.5 (0.084)
0.9 ± 1.9 (0.0001)
0.5 ± 1.5 (0.225)
0.1 ± 0.8 (0.109)
51.1 ± 17.0 (0.128) 12.8 ± 5.3 (0.026)
9.3 ± 7.4
Flexion contracture (L)
10.0 ± 8.3
0.6 ± 1.7 (0.593)
0.4 ± 1.3 (0.180)
Maximum flexion (R)
117.9 ± 17.8
115.4 ± 13.1 (0.105)
0.8 ± 1.8 (0.0001)
116.5 ± 11.8 (0.167)
114.9 ± 12.4 (0.144)
Maximum flexion (L)
117.4 ± 16.5
114.0 ± 14.0 (0.185)
115.4 ± 13.5 (0.093)
115.0 ± 12.8 (0.615)
Pre preoperative, U unilateral TKA, B bilateral TKA, R right knee, L left knee; (p value)
Fig. 1 Improvements in the JKOM scores were each statistically significant between the “Pre” and “after U” and between the “after U” and “1 year after B.” The improvement did not increase after the
1-year follow-up but was maintained at “3 years after B” (a). Each domain of JKOM showed similar changes (b)
Fig. 2 Improvements in the KSS function score were statistically significant between “after U” and “1 year after B” but not between “Pre” and “after U.” The improvement did not change further but was maintained at the “3 years after B.”
Fig. 3 Improvements in TUG were each statistically significant between “Pre” and “after U” (< 0.05), and “after U” and “1 year after B” (< 0.01). The improvements did not increase after the 1-year follow-up but were maintained at “3 years after B.”
study to evaluate QOL 3 years after bilateral TKAs in the Japanese population. Because osteoarthritis generally occurs in bilateral knees, evaluation of QOL after bilateral TKAs should be more valuable than that after unilateral TKA.
This study revealed that the improvements in JKOM and objective outcome scales (KSS and TUG) reached plateaus 1 year after the bilateral TKAs and showed no significant changes at the “2 years after B” and “3 years after B” follow-ups. The JKOM, KSS, and TUG scores showed
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Author's personal copy Quality of life after TKA Fig. 4 Improvements in the KSS score (a) and in flexion contracture (b) were statistically significant between “Pre” and “1 year after B” (< 0.01). The improvement did not change but was maintained at “3 years after B.”
Fig. 5 Longitudinal changes in the average maximum flexion of Pre, “1 year after B”, “2 years after B”, and “3 years after B” in the right knee (a) and left knee (b)
Table 3 Correlations between JKOM and KSS, TUG, and ROM The data are given as Spearman’s nonparametric correlation coefficients B bilateral TKA, R right knee, L left knee
KSS
KSS function score
JKOM 1 year after B −0.759 −0.708 2 years after B −0.834 −0.736
3 years after B −0.673 −0.632
statistically significant improvements between “after U” and “1 year after B.” In addition, Kwon et al. [9] stated that absolute postoperative subjective scores were better correlated with satisfaction than were the preoperative to postoperative changes, and that delayed surgical intervention for advanced osteoarthritis was likely to adversely affect patient satisfaction. Therefore, we recommend that contralateral TKA be performed as early as possible after unilateral TKA to maximize patients’ QOL. Miner et al. [6], Park et al. [7], and Devers et al. [10] found only weak or no correlations between maximum flexion and patient satisfaction or QOL. Pain relief alone might be enough for some patients to feel satisfied, the availability of high flexion functionality may not have meant that it was actually used, and use of flexion probably depended on an individual’s lifestyle [10]. In the current study, there were
TUG Flexion Flexion Maximum contracture (R) contracture (L) flexion (R)
Maximum flexion (L)
0.592 0.206 0.266 −0.025
0.04 −0.089
0.393 −0.153
0.006 0.105 0.078
0.009 −0.028
−0.068
−0.174
no significant correlations between maximum flexion and JKOM as well, although JKOM was statistically correlated with KSS, KSS knee score, KSS function score, and TUG. Therefore, our hypothesis that increased maximum flexion leads to better JKOM scores was false even in a Japanese population where high-flexion activities, such as bending to the floor or standing up, were sometimes required in daily living. However, there is much controversy over the correlations between maximum flexion and patient satisfaction or QOL. Padua et al. [8] found a positive correlation between ROM and patient perceptions of TKA outcome. A couple of studies also stated that increased maximum flexion (> 130° or 135°) might have better functional outcomes [7, 10]. Further investigations are needed to determine the correlations between increased maximum flexion (> 130° or 135°) and patient satisfaction or QOL in long-term follow-up periods.
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There are some limitations in this study. Basically, JKOM was developed in Japan for Japanese patients who have a specific life-style with high knee flexion activities. Although it may only be suitable for Japanese patients, it was made based on WOMAC, which is a QOL measurement tool accepted worldwide [13]. Therefore, the longitudinal evaluation of QOL in a Japanese population in this study may also be adapted for patients in other countries. Another limitation was that the sample size was small and the follow-up period was relatively short. Investigations with a larger sample size and a longer follow-up period are needed to determine how long QOL can be maintained after bilateral TKAs because QOL of elderly patients may tend to naturally worsen. However, to the best of our knowledge, this is the first longitudinal study to evaluate QOL 3 years after bilateral TKAs and our results could give useful information to TKA surgeons around the world. In conclusion, the statistically significant improvements in the JKOM, KSS scores, and TUG reached plateaus “1 year after B”, did not increase after the 1-year followup, but were maintained at “3 years after B.” There were statistically significant correlations between JKOM with KSS and TUG but not with ROM. Therefore, our hypothesis that increased maximum flexion leads to better JKOM scores was false even in a Japanese population. Conflict of interest The authors declare that they have no conflict of interest.
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