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Unhappy patient

Unhappy patient. Following a Total knee. Summary. Incidence Aetiology Diagnosis Prevention. Historically 11%-18% not satisfied with TKR. Scott C et al. Predicting dissatisfaction following total knee replacement 2010; JBJS 92-B, 9, 1253-1258. 1 Year: 18.6% not satisfied

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Unhappy patient

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  1. Unhappy patient Following a Total knee

  2. Summary Incidence Aetiology Diagnosis Prevention

  3. Historically 11%-18% not satisfiedwith TKR • Scott C et al.Predicting dissatisfaction following total knee replacement 2010; JBJS 92-B, 9, 1253-1258. • 1 Year: 18.6% not satisfied • Patient expectation • mental component score, depression and pain in other joints • Bourne et al patient satisfaction after TKR. CORR 2010,468:57-63 • Ontario 1703 primary TKR (2001-2005) • 19% Not Satisfied • Main predictor is patient expectations

  4. Painful TKR Intrinsic • Infection • Mal-alignment • Wear • Instability • Lysis • Instability • Coronal • saggital • Loosening • Soft-tissue impingement • Patellar clunk • Fabellar impingement • Popliteus tendon impingement • Component overhang

  5. Extensor mechanism problems • Patellar maltracking • Extensor mechanism disruption • (patellar fracture, patellar tendon rupture, quadricep tendon rupture) • Undersized patellar button with lateral facet impingement • Oversized patellar button with overstuffing of patellofemoral joint • Patella baja + alta

  6. Painful TKR Extrinsic • Hip pathology • Spinal disorders • Complex regional pain syndrome • Psychological disorder • Outcome expectation mismatch

  7. Diagnosis • History • Pain from start • Examination • Xray • Bloods • CT Scan • Nicoll D, Rowley DI. J Bone Joint Surg Br. 2010 Sep;92(9):1238-44 • 56% of painful TKR had internal rotation errors • Arthroscopy

  8. Prevention • Choose surgeon • Infection, mal-alignment, instability, loosening, mal-rotation • Choose patient • Choose prosthesis

  9. Infection (21%-38%)

  10. Mal-alignment

  11. Done 2005 S Johnstone 2/4/9

  12. S Johnst

  13. SJ 7/8/09

  14. E M 30/9/04 Massive posterior slope and varus cut

  15. E.M 15/7/9 5/11/2010

  16. Wear 2009 2004 Instability

  17. Wear Lysis

  18. Wear

  19. Loosening

  20. Extensor mechanismPatella tracking

  21. Extensor mechanismPatella Fracture 2009 2006

  22. other 14/8/06 15/01/08 5/2/07

  23. 1/4/09

  24. Choose patient A higher rate of complications 32% • Amin et al. J Bone Joint Surg Br. 2006 Oct;88(10):1321-6

  25. Patient Expectation • Ghandi R et al. J Arthroplasty. 2009 Aug;24(5):716-21. Patient expectations predict greater pain relief with joint arthroplasty. • a greater expectation of pain relief with surgery independently predicted greater reported pain relief at 1 year of follow-up • Singh JA, et al. Pessimistic explanatory style: a psychological risk factor for poor pain and functional outcomes two years after knee replacement. J Bone Joint Surg [Br] 2010;92-B:799–806.

  26. Patient outcome expectation mismatch

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