Patient appropriateness for total knee arthroplasty and predicted probability of a good outcome

Abstract

Objectives: One-fifth of total knee arthroplasty (TKA) recipients experience a suboptimal outcome. Incorporation of patients' preferences in TKA assessment may improve outcomes. We determined the discriminant ability of preoperative measures of TKA need, readiness/willingness and expectations for a good TKA outcome.

Methods: In patients with knee osteoarthritis (OA) undergoing primary TKA, we preoperatively assessed TKA need (Western Ontario-McMaster Universities OA Index (WOMAC) Pain Score and Knee injury and Osteoarthritis Outcome Score (KOOS) function, arthritis coping), health status, readiness (Patient Acceptable Symptom State, depressive symptoms), willingness (definitely yes-yes/no) and expectations (outcomes deemed 'very important'). A good outcome was defined as symptom improvement (met Outcome Measures in Rheumatology and Osteoarthritis Research Society International (OMERACT-OARSI) responder criteria) and satisfaction with results 1 year post TKA. Using logistic regression, we assessed independent outcome predictors, model discrimination (area under the receiver operating characteristic curve, AUC) and the predicted probability of a good outcome for different need, readiness/willingness and expectations scenarios.

Results: Of 1,053 TKA recipients (mean age 66.9 years (SD 8.8); 58.6% women), 78.1% achieved a good outcome. With TKA need alone (WOMAC pain subscale, KOOS physical function short-form), model discrimination was good (AUC 0.67, 95% CI 0.63 to 0.71). Inclusion of readiness/willingness, depressive symptoms and expectations regarding kneeling, stair climbing, well-being and performing recreational activities improved discrimination (p=0.01; optimism corrected AUC 0.70, 0.66-0.74). The predicted probability of a good outcome ranged from 44.4% (33.9-55.5) to 92.4% (88.4-95.1) depending on level of TKA need, readiness/willingness, depressive symptoms and surgical expectations.

Conclusions: Although external validation is required, our findings suggest that incorporation of patients' TKA readiness, willingness and expectations in TKA decision-making may improve the proportion of recipients that experience a good outcome.

Keywords: Knee Osteoarthritis; Orthopedic Procedures; Osteoarthritis, Knee; Outcomes research.