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Commentary & Perspective | ||||||||
Commentary on The use of outcome studies over the past twenty years has helped to refine our ideas of what truly happens after a given surgical procedure and has guided us in modifying our surgical techniques to improve on those outcomes. The use of outcome studies over the past twenty years has helped to refine our ideas of what truly happens after a given surgical procedure and has guided us in modifying our surgical techniques to improve on those outcomes. Unfortunately not all outcome measures are the same. Traditional outcome measures of total knee arthroplasty, such as the Hospital for Special Surgery rating system1 and the Knee Society rating system2,3 evaluated specific surgeon-determined parameters of knee function or patient characteristics. Some of these parameters were subjective, such as postsurgical pain. Some were objective, such as knee flexion, although even that supposedly objective measurement has been shown to vary depending on whether it is assessed with the patient sitting or recumbent, or with the knee in a weight-bearing position. Surgeons selected these parameters to measure because they thought that they were important to the patient or that they were important in predicting the long-term outcome of the arthroplasty. If the knee did not fully extend, would the components loosen or would they wear out? In the past, patient expectations were not included in the outcome evaluations. Only recently, partially because of mandates from oversight agencies, have we begun to look at the results of the surgery from the patient's perspective. If we are to counsel our patients properly, we should have some idea of what they expect after knee surgery. Mancuso et al. have devised a set of questions to help in evaluating patient expectations. In actuality, it was the patients themselves who devised the questions. The initial portion of this study was a compilation of specific questions determined from interviews with patients concerning what they felt was important, or not important, after surgery. After statistically determining which questions patients felt were most important, the authors then asked these questions to a cohort of patients who were to undergo knee surgery, either soft-tissue surgery (such as anterior cruciate ligament reconstruction) or total knee replacement. Nearly one third of the patients undergoing anterior cruciate ligament or posterior cruciate ligament reconstruction expected that the knee would be "the way it was" before injury. Over half of the patients in both the soft-tissue and the total knee replacement group expected "complete" relief of pain, which meant no pain at any time while performing any activity. Over two-thirds of the patients undergoing total knee replacement expected to be able to walk farther than one mile, regardless of their age. Clearly, such unrealistic expectations will not be realized by patients. There were realistic patient expectations, however, such as the elimination of the necessity for a cane, resumption of the ability to care for and interact with others, and the ability to either drive or use public transportation. The instrument that Mancuso et al. have devised has a major strength in that it was derived from patient information, not set by physicians who had some arbitrary concept of what they thought would be good, or not good, for the patient. This questionnaire should be used preoperatively as part of the general patient evaluation to assist patients in preparing themselves mentally for surgery and its aftereffects. Use of the questionnaire will also enable the surgeon to identify those patients who require further counseling to resolve difficulties resulting from any unrealistic expectations that they might have.
References 1. Insall JN. Results of total knee arthroplasty. In: Insall JN, editor. Surgery of the knee, 2nd ed. New York: Churchill Livingstone; 1993. p 975-82. | ||||||||
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