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J. Dattilo and W. Hamilton
8.3.2 Function andPatient Satisfaction
Hamoui etal.
2006; Issa etal. 2013), making it impos-
sible to draw denitive conclusions.
8.3.2.1 Functional Outcomes
While patient functional outcomes are not an objective etiology of TKA failure and may not constitute an
isolated reason for revision surgery, these parameters
remain crucial in evaluating outcomes of TKA.
> Function after TKA may be inuenced by a variety
of preoperative and postoperative factors.
Gender studies have demonstrated that women have
consistently lower preoperative functional scores at the
time of TKA than men, including reduced quadriceps
strength, 6-min walk test, stair-climbing times, and preoperative WOMAC scores (Lingard et al. 2004; MacDonald et al. 2008; O’Connor 1846; Petterson et al.
8
2007). Women also report worse pain than men both
before and after arthroplasty (Lingard etal. 2004; MacDonald etal. 2008; Ritter etal. 2008) and do not appear
to reach the same nal functional levels as men (Dalury
etal. 2009; MacDonald etal. 2008; Ritter etal. 2008).
Similar to other obesity-related factors and outcomes, the functional outcomes of TKA in the obese
population have yielded conicting results. Boyce etal.
reported that among morbidly obese patients, the Knee
Society Objective score (KSOS) and Knee Society
Functional score (KSFS) were poorer in morbidly obese
patients both preoperatively and postoperatively (Boyce
etal. 2019). However, the mean improvement in KSOS
in this study was the same for obese compared to nonobese patients. Obese patients have also been shown to
have lower WOMAC scores, Short Form-36 (SF-36),
and Hospital for Special Surgery (HSS) questionnaires
(Smith et al. 1992; Stickles et al. 2001). Knee Society
scores (KSS) have perhaps been the most widely used
outcome metric, but demonstrate substantially conicting results. Foran and colleagues showed that only 80%
of obese patients achieved a KSS greater than 80 points
postoperatively compared to 99% of non-obese patients
at 80-month follow-up (Foran etal. 2004a). These ndings have been replicated in multiple other studies
(Collins etal. 2012; Foran etal. 2004a, b; Grifn etal.
1998; Jarvenpaa etal. 2012). However, a nearly equal
number of studies have reported no signicant differences in scores between obese and non-obese patients
(Amin etal. 2006; Benjamin etal. 2001; Bin Abd Razak
etal. 2013; Deshmukh et al. 2002; Dewan et al. 2009;
8.3.2.2 Patient Satisfaction
> Patient dissatisfaction following TKA has been
reported as high as 20% in some studies (Husain and
Lee 2015) and has remained relatively stable over the
past several decades despite multiple changes in
implant design, surgical technique, and perioperative
pain protocols.
Outcomes have been shown to be inuenced by medical comorbidities, mental health status, socioeconomic
status, and ethnicity (Husain and Lee 2015). Regarding
socioeconomic status, patients earning annual income
less than $25,000 were less likely to be satised with
TKA outcomes and more likely to have functional limitations after TKA than patients of higher income (Barrack etal. 2014). While we have previously discussed the
increased risk of radiographic and symptomatic knee
OA in women, it does not appear that there are signicant gender differences in patient satisfaction following
TKA in women compared to men (O’Connor 1846).
Perhaps most interestingly, while obese patients have
been shown numerous times to be at risk for a multitude
of complications, poorer functional outcomes, and the
need for revision surgery following TKA, multiple studies have demonstrated comparable satisfaction scores
between the obese and non-obese (Deshmukh et al.
2002; Ersozlu etal. 2008; Yeung etal. 2011).
Conclusion
z
Knee OA is an extremely common condition affecting millions of individuals annually. However, as this
chapter exemplies, there are a myriad of patient and
lifestyle factors that can inuence the development of
OA. While some factors, notably obesity, may play a
more prominent role than others, the true pathogenesis
in the individual patient is likely multifactorial and at
present time incompletely understood. Similarly, TKA
is a very successful operation to treat end-stage OA, yet
the longevity of the implant, functional outcome, and
satisfaction may all be inuenced by a multitude of
patient factors. It is our hope that this brief overview of
many of these confounding variables provides a resource
for the practitioner to counsel patients and, where gaps
exist in our current fund of knowledge, a challenge for
future research endeavors.
Inuence of Lifestyle and Risk Factors on the Development of Knee Arthritis and Outcomes…
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83
8
Take-Home Messages
5 Women appear to be more susceptible and more
adversely affected by knee OA than men, possibly
due to hormonal exposure. The therapeutic implications for hormonal treatment, however, remain
unclear.
5 Obesity is a clear risk factor for knee OA, and
obese patients are at risk for multiple perioperative
complications, aseptic loosening, and poorer
postoperative functional outcomes. Bariatric surgery offers promising results for the obese patient
suffering from symptomatic knee OA.
5 There is limited, poor-quality evidence on diet and
nutritional supplementation in preventing or treating knee OA.
5 Exercise and sport participation have demon-
strated conicting results in their inuence on the
development of knee OA.The greatest risk appears
to be associated with activities that induce repetitive microtrauma to the joint.
5 Occupation appears to be associated with knee
OA, with more labor-intense occupations at
greater risk.
5 Activity level following TKA has not been clearly
shown to be a risk factor for aseptic loosening.
5 Satisfaction rates following TKA appear to be
associated with socioeconomic status, but these
have not demonstrated clear correlations with
other risk factors. Specically, despite higher risk
and lower functional scores preoperatively, neither
gender nor obesity has clearly demonstrated
poorer satisfaction postoperatively.
5 Cemented TKA is a successful operation to treat
end-stage arthritis of the knee. In the rst 2years,
infection was the most common reason for early
revision.
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Lifestyle andRisk Factors
forKnee Arthroplasty: ASouth
African Perspective
ZiaMaharaj andJurekRafalTomaszPietrzak
Contents
9.1 Introduction – 90
9.2 Return toWork andReturn toSports – 91
9.3 Malnutrition – 92
9.4 Undernutrition – 92
9
9.5 Overnutrition – 94
9.5.1 Associated Risks – 94
9.5.2 Functional Outcomes – 95
9.5.3 Preoperative Optimization – 95
9.6 Rehabilitation TKA – 96
References – 97
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
E. Hansen, K.-D. Kühn (eds.), Essentials of Cemented Knee Arthroplasty,
https://doi.org/10.1007/978-3-662-63113-3_9
90
1,2
*T
(TKA) procedures and 33 292 rst revisions between 2003 and 2018. (1)
Cumulative Probability Risk (%)
emale
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Z. Maharaj and J. R. T. Pietrzak
9.1 Introduction
5 Age at index surgery
5 Smoking
Total knee arthroplasty (TKA) is the most commonly
5 Nutritional status
performed joint replacement procedure worldwide.
Approximately 100,000 TKAs in the UK and 155,000
TKAs in the USA were performed in 2018 alone
(National Joint Registry 16th Annual Report 2019;
American Academy of Orthopaedic Surgeons,
American Joint Replacement Registry (AJRR) 2018).
> Younger patient cohorts have shown the highest inci-
dence of need for early revisions (National Joint
Registry 16th Annual Report 2019; American
Academy of Orthopaedic Surgeons, American Joint
Replacement Registry (AJRR) 2018)
The demand for TKA is rising and has been projected
to increase by a rate of 85% to reach 1.26million procedures annually by 2030in the USA alone (Sloan etal.
2018).
In the USA, patients under 50years of age have the highest incidence of early revision after TKA when compared
to older patient cohorts (p<0.0001) (American Academy
of Orthopaedic Surgeons, American Joint Replacement
> There is a changing demographic of a younger popu-
lation presenting for TKA as shown by a dispropor-
tionately increased demand in individuals less than
60years of age (Jain etal. 2005)
Registry (AJRR) 2018). Similar ndings have been
reported in the UK, demonstrating that young, male
patients have the highest risk for revision within 1year
after primary TKA (National Joint Registry 16th Annual
Report 2019). Furthermore, an association exists between
9
formed in the UK and 17,921in the USA, respectively.
The most common cause for early revision TKA worldwide is periprosthetic joint infection (PJI). In fact, for
63.2% of patients in the USA, PJI is the reason to present for revision surgery within 3months after the index
procedure (National Joint Registry 16th Annual Report
2019; American Academy of Orthopaedic Surgeons,
American Joint Replacement Registry (AJRR) 2018).
There are several lifestyle-related risk factors that
have been implicated in negatively impacting outcomes
including the following:
In 2008, an estimated 7733 revision TKAs were per-
an increased age at primary TKA and a decreased risk for
early revision (.
Fig.9.1). Smoking has been associated
with a 1.3-fold risk for revision TKA when compared to
patients who have never smoked (American Academy of
Orthopaedic Surgeons, American Joint Replacement
Registry (AJRR) 2018). Malnutrition is implicated in a
2–4.5 times higher risk of readmissions and revisions
compared with patients with normal nutritional status
(Carli etal. 2019; Kamath etal. 2016).
Revisions after TKA due to postoperative complications place a signicant burden on both patients and the
healthcare system.
1
0,8
0,6
. Fig. 9.1 Risk of revision within 1year after primary total knee arthroplasty (TKA). Total sample results based on 1,193,830 primary
TKA procedures and 33,292 rst revisions between 2003 and 2018 (National Joint Registry 16th Annual Report 2019)
0,4
0,2
0
<55
Age at Primary TKA (years)
otal sample results based on 1,193,830 primary Total Knee Arthroplasty
55-64 65-74
Male
F
>75
Lifestyle andRisk Factors forKnee Arthroplasty: ASouth African Perspective
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91
9
> Patients with malnutrition consume three times more
hospital resources. This results in annual costs of
$11 billion in the USA only (Carli et al. 2019;
Tappenden etal. 2013)
In comparison to healthy matched control patients,
postoperative complications due to undernutrition can
be translated into an additional expense of $3875 per
patient (Bala etal. 2020). In obese patients for TKA, an
additional cost of $250–$300 exists for every 5-unit
increase in Body Mass Index (BMI) beyond 30 kg/m2
(Martin etal. 2017; Werner etal. 2015a). These inated
costs are even more exaggerated in obese patients undergoing revision TKA with a corresponding additional
cost of $600–$650 per 5-unit increase in BMI.Increased
costs are due to expenses related to treating increased
associated medical co-morbidities, greater analgesic
requirements, increased incidence of all-cause hospitalization and total overall healthcare expenditures (Johnston etal. 2020).
> Therefore, it is imperative to identify and optimize
lifestyle and modiable risk factors prior to elective
surgery to ensure positive outcomes and mitigate the
risk of adverse events.
9.2 Return toWork andReturn toSports
A younger patient demographic has greater potential
needs for improved postoperative function and need to
return to work (RTW). Additionally, patients who participate in recreational physical activity over their lifetime are prone to develop osteoarthritis (OA) and
present for TKA at a younger age.
> Former athletes and physically active individuals have
high expectations to return to sports (RTS) after
TKA and that has been strongly correlated with
patient satisfaction.
RTW is a common goal for patients undergoing TKA
with postoperative success rates reported to range
between 68% and 85% (van Zaanen et al. 2019). The
time of RTW has been shown to vary between 8 and
12weeks after TKA (Tilbury etal. 2014). Studies have
reported a wide variation of return to sports (RTS) after
TKA (34–100%) across a spectrum of demographics
and including sports ranging across various levels of
activity (Barber-Westin and Noyes 2016).
Younger active patients aim to maintain a healthy
lifestyle and it is important for the clinician to facilitate
these goals. The American Heart Association and the
American College of Sports Medicine published guide-
lines on the levels of physical activity that have been
associated with a decreased risk prole for cardiovascular health and premature mortality. The guidelines
include both aerobic activity and muscle-strengthening
exercises with resistance training. Some studies have
associated increased activity after TKA with a higher
risk for implant wear and aseptic loosening (Garber
et al.
2011; Gerhard et al. 2013; Golant et al. 2010;
Granan etal. 2009; Harding etal. 2014) whereas others
have reported equivocal outcomes when compared to a
sedentary control cohort (Haskell et al. 2007; Healy
etal. 2008; Hopper and Leach 2008). The intensity of
activity recommended after TKA remains controversial,
in particular with regard to moderate- and high-impact
forms of exercise.
While there are no consensus guidelines concerning
the recommended level of activity after TKA, there are
two primary approaches to consider namely individualization of postoperative sports participation or didactic
instruction of permitted and non-permitted sports
activities:
5 A popular approach is to consider the premorbid
level of activity participation and individualize post-
operative exercise recommendations according to
baseline function.
5 An alternative approach is to discourage participa-
tion in moderate- to high-intensity activities for all
patients postoperatively.
The rationale behind the latter approach is that increased
intensity of activity could have predisposed the patient
to requiring TKA and, furthermore, cause postoperative complications such as implant wear. Vielgut et al.
(2016) reported a long-term follow-up study assessing
both pre- and postoperative activity levels in patients
undergoing TKA (Vielgut et al. 2016). After a mean
follow-up of 14.9 years, a signicant improvement in
pain and function was observed with some patients
being able to safely continue high-impact activities (Vielgut etal. 2016). The 1999 Knee Society Survey conveyed
a predominant opinion that minimal impact activities
such as swimming, cycling, and power walking should
be recommended as safe after TKA (Barber-Westin and
Noyes 2016; Healy etal. 2008). The benets of exercise
for overall health are undeniable and the current perspective is that surgeons should consider each case individually with the primary aim of meeting patient
expectations.
Preoperative Optimization
z
Preoperative expectations have a signicant impact
on outcomes and must be addressed in detail for each
patient. The current level of activity must be thor-
92
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Z. Maharaj and J. R. T. Pietrzak
oughly questioned and preoperative function should
be examined and documented. Advice from healthcare
practitioners can be inconsistent and not individualized to patient needs, leading to uncertainty and suboptimal postoperative outcomes (Bardgett etal. 2016).
Psychological factors, including self-motivation and an
optimistic attitude, have a positive effect on improving
patients’ outcomes (McGonagle etal. 2019).
> Extensive personalized counseling is necessary to
ensure positive and realistic expectations (van Zaanen
etal. 2019).
If the current level of function is poor or suboptimal,
there may be a role for preoperative rehabilitation.
Patients who underwent rehabilitation before TKA have
demonstrated a signicant decrease in length of hospital
stay (Sharma et al. 2019). Recommendations should
only be made after a full assessment to formulate a
directed goal-based rehabilitation program and ensure
patient satisfaction.
9.3 Malnutrition
Patients for TKA with a poor nutritional status are at
It is imperative to identify factors that enable patients
and optimize lifestyle-related barriers which may prevent patients to meet their postoperative goals, respectively.
Preoperative workup must also include patient
expectations to RTW and details of the physical level of
risk for increased complications, greater morbidity, and
high mortality rates postoperatively. (Sayeed etal. 2019)
Optimizing the nutritional status of patients undergoing elective TKA preoperatively may reduce the incidence of these complications (Jones etal. 2013; Sayeed
etal. 2019).
activity required for work-related physical tasks. Work-
9
related activities that require knee-demanding movements, such as kneeling, squatting, or crouching, remain
difcult to perform even after surgery (Kievit et al.
2014). However, operating foot pedals, standing, and
other physical activities that are less strenuous on the
> The World Health Organization (WHO) has described
the global status as a double burden of malnutrition
with the coexistence of undernutrition along with
overweight and obesity (World Health Organisation
(WHO) 2018).
knee joint can improve after TKA (Kievit etal. 2014). A
discussion with the employer may need to be facilitated
in order to ensure a successful RTW.
According to the latest WHO estimates approximately
462 million adults are underweight and 1.9 billion
adults are overweight, respectively, with over 600mil-
> Job exibility with employer-facilitated adaptations
such as better working area requirements, lighter
intensity of duties, and variable hours have shown to
have a positive impact on RTW (McGonagle et al.
2019).
lion of these categorically obese (BMI > 30 kg/m2)
(World Health Organisation (WHO) 2018). Malnutrition affects all geographic regions and spans socioeconomic population groups (World Health Organisation
(WHO) 2018). Malnutrition, including both undernutrition and overnutrition, can be dened according to
Furthermore, physically demanding duties without the
supported implementation of alterations in working
biochemical and anthropometric measurements
(. Table9.1).
condition have been associated with a negative experi-
ence of RTW and impeded patient outcomes (Bardgett
etal. 2016).
9.4 Undernutrition
There are several nonmodiable barriers to successful
RTS that have been implicated including the following:
A systematic review of 20 total joint arthroplasty (TJA)
population studies in the USA reported an incidence of
5 Age
5 Educational status
5 Complex factors such as income and domicile
undernutrition of 40–60%. However, the difculty of
identifying poor nutrition was highlighted in a review of
105 academic institutions in the USA, which reported
that undernutrition may be missed in as many as 80% of
Age over 65years is a limiting factor regarding both preand postoperative activity levels. Elderly patients are
unlikely to increase activity levels after TKA despite the
reduction in pain (Vielgut etal. 2016). Other modiable
factors include personal beliefs and motivation, social
support system, and self-efcacy. The physical effects of
surgery such as pain and fatigue have been implicated as
the primary barrier preventing RTW (Kievit etal. 2014).
cases.
Undernutrition has been associated with male gender
and revision surgery but not with age. Despite the prevalence and consequences of undernutrition, there are no
standardized guidelines for screening, risk stratication,
or management protocols for patients undergoing
TKA.Anthropometric measurements are less accurate
than biochemical markers at identifying undernutri-
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