Moderator Thornhill: You both talked about the 15%-20% of dissatisfied or less than fully satisfied patients in a relatively pithy way. Tell me what is the source of this dissatisfaction and how we can make it better?
Dr. Sculco: Dissatisfaction, it’s multifactorial. Depression, anxiety, fibromyalgia, catastrophizing, and low preoperative Knee Society Scores. We all use that 20% as an explanation but if you look at the data, a lot things that cause the dissatisfaction are not related to the knee itself.
Dr. Nam: I think the number one reason is unmet expectations.
Moderator Thornhill: You’ll see patients who have total hips and they forget they had anything done; they’ll have a total knee and are still the same depressed, catastrophizing, melancholic person. Why does their knee hurt and their hip doesn’t?
Dr. Nam: I think a knee replacement is a more difficult surgery to perform. Setting patient expectations is critical. I would also say that this debate is great and it’s fun to argue and talk about alignment but we are looking at only 2D static images. When you have a patient’s dynamic constraints, muscle tone and gait analysis the story can be totally different. It’s really hard to say that patients are going to do well just based on their radiograph.
Moderator Thornhill: Okay Denis, George Santayana once said that those who forget about history are doomed to repeat it. The fact is that some of the kinematic alignment is like the alignment in the old PCA. Is that okay?
Dr. Nam: I think the PCA failed for a number of reasons; one of them was the patella-femoral complication. I think that when we look at these alignment targets we should be starting with boundaries and I don’t think anyone is going to stand up and say a 7-degree varus tibia is okay. I think that there are boundaries where maybe a 2-degree varus tibia is okay or 3-degree, or having a little bit of valgus at the distal femur. I think we should start with the kind of less severe deformities and see if that truly makes a difference because I honestly think those are the patients we have the most difficulty with. The severe valgus deformity or the severe varus deformity, if we can get them a stable, balanced knee, I think those patients tend to do okay.
Moderator Thornhill: Thank you, you guys have really helped us.
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Senior Editor: Jay D. Mabrey, M.D., whose 35 year career in orthopedics included residency at Duke University Medical Center, service in the United States Army Medical Corps, Fellowship at the Hospital for Special Surgery and a long, distinguished career at Baylor University Medical Center where, in addition to his overall leadership at that institution, developed the Joint Wellness Program that helped patients get up after surgery more quickly, developed the first virtual reality surgical simulator for knee arthroscopy and chaired the FDA Orthopaedic Device Panel, is Orthopedics This Week’s newest contributing writer and editor.
