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Expectations of recovery from revision knee replacement.

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Arthritis & Rheumatism (Arthritis Care & Research)
Vol. 55, No. 2, April 15, 2006, pp 314 –321
DOI 10.1002/art.21856
© 2006, American College of Rheumatology
ORIGINAL ARTICLE
Expectations of Recovery From Revision
Knee Replacement
VIJI VENKATARAMANAN,1 MONIQUE A. GIGNAC,2 NIZAR N. MAHOMED,3
AND
AILEEN M. DAVIS4
Objective. To evaluate outcome expectations of patients undergoing revision total knee replacement (TKR) and to
examine personal factors, patient functioning, previous experiences with knee replacement surgery, concerns about
surgery, and general health as predictors of expectations.
Methods. Revision TKR patients (n ⴝ 184, 54% women; mean age 69 years) completed a questionnaire up to 2 weeks
before surgery. This included demographics, experience with previous knee surgery, concerns about surgery, the Life
Orientation Test (LOT), the Arthritis Helplessness Scale, the Western Ontario and McMaster Universities Osteoarthritis
Index, and a rating of overall health. Outcome expectations were evaluated as 5 questions assessing global benefit; relief
of pain; ease of disability; expectations of having complications; and whether the person expected to be fully recovered
from surgery in <6 months, 6 –12 months, >12 months, or did not expect to recover. Predictors of each of the 5 outcome
expectations were evaluated using univariable and multivariable regression analyses.
Results. Expectations are a multidimensional construct (Cronbach’s ␣ ⴝ 0.63). Expectation of global benefit of surgery
was high, but was lower for benefits related to ease of pain and improved function. Concerns about surgery were a
consistent predictor of all expectation outcomes in multivariable modeling. When concerns about surgery and general
health were entered into the model as an interaction with expectation of recovery time as the outcome, past experience
(P ⴝ 0.05), pain (P ⴝ 0.03), LOT (P ⴝ 0.03), and interaction between concerns about surgery and general health were
significant predictors.
Conclusion. Clinicians need to understand and help patients shape appropriate expectations for recovery from revision
TKR.
KEY WORDS. Revision total knee replacement; Recovery; Predictors.
INTRODUCTION
Osteoarthritis (OA) is a major cause of disability (1), and
the knee is the second most commonly affected joint (2). In
the US population, 16.3% of 24 –75-year-olds have some
form of arthritis or rheumatism and 75% (12.3% of the US
Supported by an operating grant from the Canadian Institutes of Health Research.
Dr. Davis’s work was supported by a health career award
from the Canadian Institutes of Health Research.
1
Viji Venkataramanan, MA: Toronto Rehabilitation Institute, Toronto, Ontario, Canada; 2Monique A. Gignac, PhD:
Toronto Western Hospital, University Health Network, and
the University of Toronto, Toronto, Ontario, Canada; 3Nizar
N. Mahomed, MD, FRCSC, Dphil: Toronto Western Hospital,
and the University of Toronto, Toronto, Ontario, Canada;
4
Aileen M. Davis, PhD: Toronto Rehabilitation Institute, and
the University of Toronto, Toronto, Ontario, Canada.
Address correspondence to Aileen M. Davis, PhD, Room
1119, Toronto Rehabilitation Institute, 550 University
Avenue, Toronto, Ontario, Canada M5G 2A2. E-mail: davis.
aileen@torontorehab.on.ca.
Submitted for publication March 8, 2005; accepted in
revised form September 29, 2005.
314
population) have OA (3,4), whereas in Canada 4 million
individuals are living with OA. It is estimated that in
Canada there will be a 45% increase in the prevalence and
an 88% increase in the number of persons affected by
arthritis-associated disability between 1985 and 2020 (5).
The World Health Organization suggests similar increasing rates in Europe and developing countries as longevity
increases (1). For individuals with moderate to severe OA
of the knee, total knee replacement (TKR) is a cost-effective treatment because it reduces pain and disability (6).
However, as primary joint implants loosen and fail, revision surgery is required.
Patients’ expectations that a treatment or behavior will
achieve its desired effect are a key factor in understanding
health treatments and outcomes (7,8). For example, patient
expectations have been linked to requests for elective
treatments, compliance with medical regimens, prediction
of functional outcomes, and satisfaction with outcomes
(9 –14). However, only a few studies (largely retrospective)
have reported on the expectations of patients undergoing
primary total joint replacement (15–17). Moreover, although Haddad et al (18) and Eisler et al (10) evaluated
Revision Knee Replacement
expectations in persons undergoing revision total hip replacement, no reports exist of expectations of patients
undergoing revision TKR.
Previous research has focused on a single dimension of
expectations, most often expectations of satisfaction or
expectations of returning to a previous level of functioning
(13,17,18). We do not know to what extent patients’ expectations form a global evaluation of TKR or are varied
and multidimensional in nature. If patients have different
types of expectations regarding TKR, this has implications
for targeting areas that may need to be addressed to better
educate patients and to assist them in decision making.
Theories of social cognition have posited that factors
such as perceived vulnerability, previous experience, and
individual differences may shape individuals’ expectations (7,8). Therefore, examining expectations in revision
TKR may be particularly important because patients have
previous (unsuccessful) experience with the procedure
and may report greater vulnerability or concerns. This,
ultimately, may affect the outcome of surgery. As a first
step in uncovering the role of expectations in revision
TKR, we examined personal factors, patient functioning,
previous experiences with knee replacement surgery, concerns about surgery and general health, and the relationship of these factors to patients’ expectations prior to receiving revision TKR.
PATIENTS AND METHODS
Patients. This study was a cross-sectional analysis of
patients undergoing revision TKR surgery nationwide (in
teaching hospitals in Halifax, London, Toronto, Winnipeg,
and Vancouver). Surgeons used their usual criteria (which
included a combination of pain, functional deficit, instability, and radiographic loosening or bone loss) for recommending revision TKR surgery. Inclusion criteria for the
study were as follows: patient was considered a candidate
for revision TKR by the surgeon, had a previous TKR for
arthritis, was able to speak and read English, and gave
consent to participate. Exclusion criteria included revision
TKR for infection, patellar revision only, or polyethylene
liner exchange only. Ethics approval was obtained from
each participating institution, and all participants consented to participate in the study.
Measures. This study focuses on the baseline data of a
prospective longitudinal study collecting data over 5 years
that will evaluate predictors of various outcomes (i.e.,
pain, disability, satisfaction) in patients undergoing TKR.
Participants completed a set of questionnaires (detailed
below) 2 weeks prior to their surgery at their preadmission
clinic visit. Demographic data including age, sex, marital
status, and education level were collected. We also asked
how many prior knee replacement surgeries the individual
had on either of their knees. Outcome variables were outcome expectations, and predictor variables were dispositional optimism as measured by the Life Orientation Test
(LOT) (19), preoperative pain and physical function as
measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) (20 –22), experience
315
with previous TKR, Arthritis Helplessness Scale (AHS)
scores (23), perception of control over decision making
about having the surgery, concerns about the surgery, and
overall general health and general health in relation to the
knee.
Outcome expectations were evaluated as 5 separate
questions. Three questions assessed expectations concerning global benefit, relief of pain, and ease of difficulties
with daily activities based on a 5-point scale (where 1 ⫽
extremely beneficial and 5 ⫽ not at all beneficial). In
question 4, respondents indicated if they expected to have
complications (no, yes, or not sure). In question 5, patients
were asked whether they expected to be fully recovered
from their surgery in ⬍6 months, 6 –12 months, ⬎12
months, or did not expect to ever recover. Our intent was
to scale these 5 items into a summative score; however,
Cronbach’s alpha was 0.63. (Cronbach’s alpha is a measure
of internal consistency. It measures how well a set of items
or variables measures a single unidimensional latent construct.) The interitem correlations were low (ranging from
0.14 to 0.41), with item-total correlations ranging from
0.36 to 0.43, explaining the low Cronbach’s alpha value.
This low alpha indicates that expectations are a multidimensional construct, and therefore we evaluated each of
the 5 expectation questions as separate outcomes.
The LOT is a reliable and valid measure of optimism/
pessimism (19) and consists of 12 items: 4 positively
worded items, 4 reverse-coded items, and 4 filler items.
The score ranges from 8 to 40, indicating extreme optimism and a negative orientation to life, respectively.
The AHS is a shortened version of the Arthritis Helplessness Index with similar predictive properties and acceptable reliability (23–27). This 5-item scale, with a maximum score of 25 and minimum score of 5, measures
individuals’ perceptions of their helplessness in managing
their arthritis. A high score indicates helplessness in managing arthritis.
The WOMAC is a reliable and valid measure of symptoms and function for persons with OA of the hip and/or
knee, and has been used extensively as an outcome for
total joint replacement (20 –22). The WOMAC consists of 3
subscales: pain, stiffness, and physical function. Only the
pain and physical function subscales were used in this
study. The pain score ranges from 0 to 20 and the physical
function scale ranges from 0 to 68. Higher scores indicate
more pain or disability.
Five questions relating to past experience in terms of
recovery time, complications, pain, difficulty with daily
activities, and benefit experienced from the previous surgery were combined to form the Past Experience Scale
(Cronbach’s ␣ ⫽ 0.80). Three questions assessed previous
experience with knee replacement surgery concerning
global benefit, relief of pain, and ease of difficulties with
daily activities based on a 5-point scale (where 1 ⫽ extremely beneficial and 5 ⫽ not at all beneficial). Question
4 asked if patients experienced or did not experience complications, and question 5 asked patients whether they
recovered from their previous surgery in ⬍6 months, 6
months to 1 year, ⬎1 year, or never recovered. The summative score ranges from 5 (a very positive or good expe-
316
rience with the previous knee surgery) to 21 (a negative or
bad experience).
Five questions relating to a patient’s concerns in terms
of the surgery (overall concern, pain, complications, recovery, and difficulty with everyday activities) were graded
on a 5-point scale (where 1 ⫽ not at all and 5 ⫽ extremely).
These questions were combined to form the Concerns
Scale, as internal consistency as measured by Cronbach’s
alpha was 0.83. A maximum score of 25 indicates extreme
concern whereas the minimum score of 5 indicates no
concerns with the surgery.
Perception of control was evaluated by asking patients
to indicate the extent to which they thought the decision to
have the knee revision surgery was outside of their control.
Responses were indicated on a 5-point scale ranging from
“not at all” to “a great deal.”
Patients rated their general health on a visual analog
scale with gradation from 0 to 100, where 0 represents
“worst imaginable health state” and 100 represents the
“best imaginable health state” (28). The knee health rating
scale is the same as the general health rating scale, but it
records patients’ perceptions of their health with respect
to their knee.
Statistical analyses. Descriptive statistics were calculated for all the variables. As noted above, Cronbach’s
alpha was calculated to determine if there was sufficient
homogeneity to create summated scales for the past experiences with surgery, concerns, and expectations questions.
Univariate regression analyses were performed to determine the factors influencing individual expectations,
namely expectation of benefit from surgery, expected recovery time from surgery, expectation of complications
during recovery from surgery, expectation of pain, and
expectation of difficulties in performing daily activities.
Variables from the univariate regression analysis that were
significant at P ⬍ 0.10 were entered into multiple linear
regression models for each of the 5 expectation questions.
Before embarking on the regression analyses, we computed correlations (Kendall’s tau and Spearman’s correlation) for the different domains of expectations and also
between the predictor variables to check for high correlation values indicating colinearity. As a final component to
testing the multivariable models, we tested an interaction
between the Concerns Scale and perceived general health
to address whether patients with lower levels of health
status had more concerns and whether the interaction of
the 2 variables was, in turn, related to expectations. We
explored this interaction based on the hypothesis that
patients who had poorer general health may be more concerned about having surgery and their recovery. P values
⬍0.05 were considered statistically significant.
RESULTS
The sample consisted of 184 patients who were undergoing revision TKR. A total of 99 (53.8%) patients were
women. The mean age was 69 years, the youngest patient
being 32 years of age and the oldest patient being 89 years
of age. A total of 120 (65.6%) were married or with a
Venkataramanan et al
Table 1. Description of the sample (n ⴝ 184)*
Characteristic
Value
Women
Married or with a partner
Living alone
Bachelor’s degree or higher
Other medical problems
Help around the house
Using walking aid
Taking pain medication
Age, mean ⫾ SD years (range)
Number of previous
replacement surgeries,
mean ⫾ SD (range)
Arthritis Helplessness Score,
mean ⫾ SD (range)
Life Orientation Test,
mean ⫾ SD (range)
Concerns About Surgery
scale, mean ⫾ SD (range)
Past Experience scale,
mean ⫾ SD (range)
WOMAC pain subscale,
mean ⫾ SD (range)
WOMAC physical subscale,
mean ⫾ SD (range)
General health rating by
patient, mean ⫾ SD (range)
General health with respect to
knee, mean ⫾ SD (range)
99 (53.8)
120 (65.6)
48 (26.2)
16 (8.7)
136 (75.1)
140 (76.1)
144 (79.1)
28 (15.4)
69.1 ⫾ 11.3 (31.9–89.4)
1.9 ⫾ 1.1 (1–8)
15.0 ⫾ 4.0 (5.0–25.0)
17.7 ⫾ 4.9 (8.0–34.0)
15.0 ⫾ 4.0 (5.0–25.0)
12.8 ⫾ 4.1 (5.0–21.0)
11.1 ⫾ 3.9 (3.0–20.0)
38.6 ⫾ 12.8 (14.3–52.5)
73.5 ⫾ 18.7 (10–100)
39.2 ⫾ 22.1 (0–90)
* Values are the number (percentage) unless otherwise indicated.
WOMAC ⫽ Western Ontario and McMaster Universities Osteoarthritis Index.
partner; 48 (26.2%) lived alone; and the remainder lived
with family members, friends, or in a residential institution. For education level, 8.7% had a bachelor’s degree or
higher. On average, patients had 1.9 previous knee replacement surgeries with a maximum of 8 prior surgeries
on index and nonindex knees combined (Table 1).
The mean ⫾ SD score on the AHS was 15.0 ⫾ 4.0,
suggesting that most patients were in the middle range of
the scale in reporting helplessness in dealing with their
arthritis. The LOT scores revealed that patients were generally optimistic (mean ⫾ SD score 17.7 ⫾ 4.9). The Concerns Scale had a mean ⫾ SD score of 15.0 ⫾ 4.0, indicating that patients were only somewhat concerned about
surgery. Patients’ past experience with knee revision surgery was unremarkable as suggested by the mid-range
scores (mean ⫾ SD score 12.8 ⫾ 4.1). The WOMAC pain
and physical subscales had mean ⫾ SD scores of 11.1 ⫾ 3.9
and 38.6 ⫾ 12.8, respectively. Patients regarded their overall general health as being good (mean ⫾ SD 73.5 ⫾ 18.7)
but rated their health as poor with respect to their knee
(mean ⫾ SD 39.2 ⫾ 22.1).
Most patients had relatively high expectations (Table 2).
A total of 54.9% believed the upcoming surgery would be
extremely beneficial in helping them resume their everyday activities (group mean ⫾ SD 1.7 ⫾ 0.8). Half of the
patients undergoing revision TKR (51.1%) expected to recover in ⬍6 months after surgery, whereas a slightly lower
Revision Knee Replacement
317
Table 2. Percentage of response, number of patients, and
mean ⴞ SD for each of the 5 expectations
Expectation/response
options
Global benefit
1 (extremely)
2
3 (somewhat)
4
5 (not at all)
Pain
1 (extremely)
2
3 (somewhat)
4
5 (not at all)
Difficulty
1 (extremely)
2
3 (somewhat)
4
5 (not at all)
Recovery time, months
⬍6
6–12
⬎12
Do not expect to recover
Complications
No
Not sure
Yes
Mean ⴞ SD
No. (%)
1.7 ⫾ 0.8
100 (54.9)
43 (23.6)
37 (20.3)
1 (0.5)
1 (0.5)
3.4 ⫾ 0.9
27 (14.8)
35 (19.2)
108 (59.3)
8 (4.4)
4 (2.2)
beneficial effects from surgery, with a trend for age (P ⫽
0.08).
Expectations of recovery time. Expectation of a shorter
recovery time was associated with having low concerns
about the upcoming surgery (P ⬍ 0.0001), a positive past
experience with surgery (P ⬍ 0.0001), experiencing pain
(P ⬍ 0.0001), having difficulty with physical functioning
(P ⬍ 0.0001), low feelings of helplessness (P ⫽ 0.001),
optimism (P ⫽ 0.001), and higher education (P ⫽ 0.04), as
was evident from univariate regression analyses. Expectation of a faster recovery was predicted by low concerns
about surgery (P ⫽ 0.003), with a trend for positive past
surgical experiences (P ⫽ 0.06) and higher education (P ⫽
0.06) when the variables from the above univariate analyses were entered into a multiple linear regression model.
3.2 ⫾ 0.9
22 (12.1)
26 (14.3)
117 (64.3)
9 (4.9)
8 (4.4)
1.5 ⫾ 0.6
93 (51.1)
82 (45.1)
6 (3.3)
1 (0.5)
1.4 ⫾ 0.6
108 (59.0)
68 (37.2)
7 (3.8)
number of patients (45.1%) thought they would recover
between 6 months and 1 year. The remainder believed that
it would take longer than 1 year or that they would never
fully recover. In terms of expecting complications, more
than half the patients (59%) did not expect to experience
any complications. A total of 59.3% expected the recovery
to be somewhat painful. Expectation of difficulty with
respect to everyday activities during recovery was similar
to expectation of pain, with 64.3% expecting a somewhat
difficult recovery, 14.3% expecting between somewhat
and extreme difficulty, and 12.1% expecting extreme difficulty. The others thought it would be somewhat or not at
all difficult.
Predictor variables were not highly correlated, with the
correlation values ranging from 0.01 to 0.59. WOMAC pain
and physical subscales had the highest correlation (r ⫽
0.59).
Expectations of benefit. Univariate regression analyses
revealed that low concerns about surgery (P ⬍ 0.0001),
optimism (P ⫽ 0.001), positive past experience (P ⫽
0.005), perceiving overall health as good (P ⫽ 0.01), older
age (P ⫽ 0.02), and seeing one’s self as being responsible
for the decision to have surgery (P ⫽ 0.037) were associated with perceptions of increased benefits of surgery.
However, when the above variables were entered into a
multiple linear regression model (Table 3), only low concerns about surgery (P ⫽ 0.02) was predictive of perceived
Expectations of complications. Univariate regression
analyses revealed that being less concerned about surgery
(P ⬍ 0.0001), having a positive past surgery experience
(P ⫽ 0.001), optimism (P ⫽ 0.002), and not feeling helpless
(P ⫽ 0.04) were all associated with low expectations of
complications, whereas older patients (P ⫽ 0.006) and
those who did not rate their general health as high (P ⫽
0.02) expected complications to arise while recovering
from surgery. Multiple regression analysis revealed that
concerns about surgery (P ⫽ 0.004) and age (P ⫽ 0.05) were
the only independent predictors of expectation of complications during recovery from surgery.
Expectations of pain. Univariate regression analyses
demonstrated that expectations of pain were low for
women (P ⫽ 0.08), when concerns about surgery were low
(P ⬍ 0.0001), when patients had a positive past experience
with surgery (P ⬍ 0.0001), when current pain was low (P ⫽
0.01), when patients did not feel helpless (P ⫽ 0.03), and
when physical functioning was higher (P ⫽ 0.04). Expectations of pain were high when the patients were older
(P ⫽ 0.04), had fewer numbers of previous replacement
surgeries (P ⫽ 0.10), or perceived themselves to have
poorer overall health (P ⫽ 0.04). The only significant predictor of expectations of pain was concerns about surgery
(P ⬍ 0.0001) when the above variables were entered into
the multiple regression analysis.
Expectations of difficulty with everyday activities. Univariate regression analyses showed that patients expected
less difficulty with everyday activities after surgery when
they were less concerned about surgery (P ⬍ 0.0001), female (P ⫽ 0.08), had a positive past experience with surgery (P ⫽ 0.002), and did not feel helpless (P ⫽ 0.02). Upon
entering the above variables into a multiple linear regression model, expectation of experiencing fewer difficulties
with everyday activities after surgery was predicted by low
concerns about surgery (P ⫽ 0.03). There was a trend
toward significance for past experience with surgery (P ⫽
0.07).
Interaction. An interaction between concerns about
surgery and general health as perceived by the patient was
318
Venkataramanan et al
Table 3. Predictor variables (P < 0.10) in multivariable regression models*
Predictor variables
Expectation of benefit (R2 ⫽ 0.17; n ⫽ 162)
Concerns about surgery
Life Orientation Test
Past Experience Scale
General health
Age
Responsible for decision
Expected recovery time (R2 ⫽ 0.27; n ⫽ 164)
Concerns about surgery
Past Experience Scale
WOMAC pain subscale
WOMAC physical subscale
Arthritis Helplessness Scale
Life Orientation Test
Education
Expectation of complications (R2 ⫽ 0.16; n ⫽ 162)
Concerns about surgery
Past Experience Scale
Life Orientation Test
Age
General health
Arthritis Helplessness Scale
Expectation of pain (R2 ⫽ 0.16; n ⫽ 160)
Concerns about surgery
Past Experience Scale
WOMAC pain subscale
WOMAC physical subscale
Arthritis Helplessness Scale
General health
Age
Sex
Previous surgeries
Expectation of difficulty (R2 ⫽ 0.22; n ⫽ 170)
Concerns about surgery
Past Experience Scale
Arthritis Helplessness Scale
Sex
␤
SE
t
P
0.037
0.018
0.015
⫺0.003
⫺0.360
0.079
0.015
0.014
0.018
0.004
0.208
0.049
2.435
1.316
0.841
⫺0.928
⫺1.726
1.612
0.016
0.190
0.402
0.355
0.086
0.109
0.029
0.022
0.030
0.002
⫺0.010
0.015
⫺0.028
0.010
0.011
0.019
0.006
0.014
0.009
0.015
2.970
1.910
1.568
0.336
⫺0.743
1.646
⫺1.896
0.003
0.058
0.119
0.737
0.459
0.102
0.06
0.029
0.008
0.012
⫺0.273
0.000
0.000
0.010
0.012
0.009
0.136
0.002
0.012
2.952
0.733
1.291
⫺2.011
0.020
0.019
0.004
0.465
0.199
0.046
0.984
0.985
0.064
0.020
0.039
⫺0.008
⫺0.0013
⫺0.001
⫺0.222
⫺0.109
⫺0.038
0.016
0.018
0.030
0.009
0.022
0.004
0.216
0.134
0.061
4.085
1.100
1.281
⫺0.926
⫺0.598
⫺0.301
⫺1.030
⫺0.814
⫺0.613
⬍ 0.0001
0.273
0.202
0.356
0.551
0.764
0.305
0.417
0.541
0.032
0.032
0.007
⫺0.207
0.015
0.018
0.018
0.131
2.144
1.781
0.389
⫺1.581
0.034
0.077
0.698
0.116
* WOMAC ⫽ Western Ontario and McMaster Universities Osteoarthritis Index.
entered into the above multivariate models to understand
if patients with lower levels of health status had more
concerns and if the interaction of the 2 variables was, in
turn, related to expectations. This interaction was significant in the model with expected recovery time as the
outcome variable. Including this interaction term in the
multivariable model resulted in optimism (P ⫽ 0.03), experiencing pain (P ⫽ 0.03), and the interaction between
concerns about surgery and perceived general health (P ⫽
0.03) becoming significant predictors, along with having a
good past experience with surgery (P ⫽ 0.05). However,
concerns about surgery were no longer a significant predictor, indicating that concerns about surgery were moderated by patients’ perceptions of their general overall
health in predicting expectations about recovery time from
surgery (Figure 1). Specifically, the interaction revealed
that at low levels of general health, patients’ concerns
about surgery did not influence their expectations of recovery. Most of these individuals believed they would
recover within a year. Among those with higher ratings of
Figure 1. Interaction between general health rating and concerns
about surgery in relation to expected recovery time. 1 ⫽ recover in
⬍6 months; 2 ⫽ recover in 6 months to a year; 3 ⫽ recover in more
than a year; 4 ⫽ do not expect to ever recover.
Revision Knee Replacement
general health, a different pattern emerged. Despite having
better reported health, patients with high ratings of general
health who reported greater concerns about surgery reported the longest expected recovery times compared with
all other groups.
When the interaction between concerns for surgery and
general health as rated by the patient was replaced with
the interaction between concerns about surgery and
WOMAC physical subscale score, no significant change
was noted in any model except for the expected recovery
time model. Patients’ previous experiences with surgery
(P ⫽ 0.08), optimism (P ⫽ 0.09), higher education (P ⫽
0.06), and the interaction between concerns about surgery
and WOMAC physical functioning scores (P ⫽ 0.07) predicted patients’ expectation of a faster recovery. When the
interaction variable in the above models for the 5 expectations was replaced with the interaction between concerns about surgery and WOMAC pain subscale score, no
significant change was found in any of the models.
DISCUSSION
Revision total joint replacement is more complex than
primary replacement, and with increased volume of primary total joint replacement, revision total joint replacement rates are also increasing (29). Currently, there are
little data available on the outcomes of revision TKR (30)
with which to guide patients, and there are no data on
what patients expect after revision TKR. Previous work
has evaluated expectations of patients undergoing primary
hip or knee replacement or revision hip replacement with
the intent of evaluating how expectations relate to functional outcome and satisfaction with outcome (13,15–18).
To our knowledge, this is the first study that has evaluated
expectations of patients undergoing revision TKR and that
has attempted to understand factors that shape patients’
expectations about their recovery from surgery.
In capturing expectations, we included an overall question of expected benefit as well as several questions related
to specific benefits expected in terms of symptoms and
function. When tested, these items were not homogeneous
based on a low Cronbach’s alpha, suggesting that expectations about recovery following revision TKR are formed
from distinct components. If expectations were a homogeneous concept, we would also expect similar factors to
predict expectations. However, our modeling of various
factors demonstrated that the predictors varied depending
on which expectation question was the dependent variable. In the total joint replacement literature, expectations
have been evaluated by individual questions similar to our
study and by summing the responses to individual items
(13,15–18). It is unclear if these summed scales reflect a
homogeneous concept. The multidimensional nature of
expectations revealed in this study suggests that studies
need to evaluate multiple aspects of expectations and ultimately look at how these different expectations relate to
outcome. Also, further work needs to be done to determine
if individuals have additional expectations that have not
been evaluated.
Despite the fact that their knee replacement failed, pa-
319
tients expected the overall benefit from their revision TKR
to be high (mean 1.68); however, their expectations of
specific benefits in pain relief and disability were less
positive (mean 3.40 and 3.25, respectively). (For these
questions, 1 indicated a higher level of expectation.) In
this study, the indications for revision TKR included pain,
functional deficit, instability, and radiographic loosening
or bone loss. It is rare that radiographic loosening, bone
loss, or instability would occur without the patient experiencing pain and/or functional compromise. It is, therefore, unexpected that patients would have high global
expectations with much lower expectations for pain relief
and functional recovery. This suggests that global expectations may represent additional specific expectations that
were not evaluated by our questions.
In this study, most patients reported relatively high expectations from their surgery. Although there is a fair
amount of variability in patients’ expectations of recovery,
complications, pain, and potential interference with daily
activities, on average patients expect the recovery to be
without complications, the surgery to be extremely beneficial, some pain, and some amount of difficulty with daily
activities. Patients expect to be fully recovered or to be
near full recovery in 6 months. Similar results of high
expectations have been reported in studies on patients
who underwent primary total joint replacement and revision total hip replacement (10,16 –18). Saleh et al concluded that revision TKR is a beneficial procedure (30).
However, their meta-analysis was based on a clinician’s
global ratings of pain, function, and range of motion rather
than the patients’ perceptions of their function, and the
data provide no indication of the timeline of recovery.
Only through a longitudinal study of recovery will we be
able to determine if these expectations match true recovery
and predict outcome.
Although research shows that past experience may
shape individuals’ expectations (7,8), there seems to be no
known scale measuring past experience of patients, especially in relation to surgery outcomes. To determine the
relevant domains of interest, we drew extensively from
research on total joint replacements, consequently suggesting the outcomes, namely pain, recovery, difficulty resuming daily activities, complication, and benefit to be the
most relevant to surgery (10,12,15–17,30,31). Our preliminary analyses of the scale indicate an acceptable internal
reliability (Cronbach’s ␣ ⫽ 0.80). Past experience was only
predictive of expectation of recovery time. There may be
other aspects of past experience that might be relevant to
the other domains of expectation. More research is needed
to assess how patients’ previous experiences might be a
factor associated with outcomes of surgery, and also to
validate the domains of expectation in other samples.
Sex and individual differences in optimism and perceptions of helplessness related to arthritis were not related to
the expectations that patients have about revision TKR.
However, patients’ concerns about surgery were a significant factor in shaping their expectations of global benefit,
complications, pain relief, and difficulty with daily activities. Even considering that we had multiple expectation
outcomes, these findings are consistent, with the exception of expectations of difficulty with daily activities, had
320
a Bonferroni correction been used where a significant P
value would be 0.01. In a study of patients undergoing
primary total knee and total hip arthroplasty, Trousdale et
al also found patients to be concerned about pain after
surgery and the length of recovery (31). These results suggest that individual, relatively stable characteristics such
as sex and optimism may not be as important in determining expectations as situational or specific contextual factors such as concerns or worries about different aspects of
surgery.
Concerns about surgery interacted with general health
status to predict expected time to recovery. When patients
rated their overall health as low, there was little variability
in the recovery time, irrespective of concerns about surgery. This expectation of a relatively short recovery time
regardless of concerns about surgery may mean that, at low
levels of general health, patients are focused primarily on
their current health and are motivated to do something to
alleviate their pain and disability. As a result, they expect
that surgery will allow them some degree of recovery in a
relatively short time. The implications for this expectation
warrant further study, particularly because older patients
with more comorbidities are undergoing revision surgery
(29) and their expectations of recovery time may not be
realized. When general health is higher, the focus may not
only be on improving health status but also on the costs
and benefits of the surgery itself. Individuals with concerns may be more likely to question their decision to go
ahead with surgery and more likely to expect a longer
recovery time. It is unclear whether these expectations
will be more realistic in terms of actual outcomes than the
expectations of individuals in other groups. Future research would benefit from examining the concordance of
patients’ expectations of recovery with outcomes.
In summary, most of the patients undergoing revision
TKR in this study expected their surgery to be extremely
beneficial. Most expected to recover within a year of surgery, and more than half expected not to experience complications after surgery but to have a somewhat painful
and difficult recovery period with respect to performing
everyday activities. Concerns about surgery are the most
significant factor influencing expectations about revision
TKR surgery. In addition, past experience also influenced
expectation of recovery time, while age seemed to influence expectation of complications. Understanding these
individual expectations has implications for targeting areas that may need to be addressed to better educate patients and to assist them in understanding their recovery
and the extent of recovery following revision TKR, particularly as work in primary joint replacement has shown
that expectations are a predictor of outcome (17).
ACKNOWLEDGMENTS
We would like to acknowledge the contributions of the
lead surgeons at each of the centers where patients were
accrued to this study: Dr. Michael Dunbar, Queen Elizabeth II, Halifax, Nova Scotia; Dr. Steve MacDonald, London Health Sciences Center, London, Ontario; Dr. Nizar
Mahomed, Toronto Western Hospital, Toronto, Ontario;
Dr. Allan Gross, Mount Sinai Hospital, Toronto, Ontario;
Venkataramanan et al
Dr. Jeffrey Gollish, Sunnybrook and Women’s College
Health Science Center, Toronto, Ontario; Dr. Emil
Schemitsch, St. Michael’s Hospital, Toronto, Ontario; Dr.
David Hedden, St. Boniface General Hospital, Winnipeg,
Manitoba; Dr. Donald Garbuz, Vancouver General Hospital, Vancouver, British Columbia.
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