A fascinating new study illuminates a particular corner of research that may, finally, unlock the key to the stubbornly high (20%) rate of patient dissatisfaction with their total joint replacement.
And, importantly, this paper opens up a highly attractive new, and under-investigated avenue of research. Any young orthopedic surgeon seeking to make their mark, should take notice. Psychology of joint arthroplasty is wide open.
This new study lays the foundation. Titled: “The Impact of Psychological Factors and Their Treatment on the Results of Total Knee Arthroplasty,” the paper was published in the September 15, 2021, edition of The Journal of Bone and Joint Surgery.
A Burgeoning Research Arena
Co-author Robert L. Barrack, M.D., the Charles and Joanne Knight Distinguished Professor in the Department of Orthopaedic Surgery at the Washington University School of Medicine in St. Louis, explained the genesis of this study to OTW, “We felt that it was an ideal time for a review article for total joint surgeons in which the terminology and definitions of the major psychological conditions which have been shown to impact the results of total knee replacement could be summarized along with the results of studies published in recent years showing a significant impact on patient satisfaction as well as complication rates. The timing is right because of the dramatic increase in studies of this type and the lack of familiarity of many surgeons in this domain.”
Better Implant Design ≠ Increased Satisfaction
“The high (20%) dissatisfaction rate following TKA has been well known for 10-20 years,” says Dr. Barrack. “Numerous changes in component design and surgical technique have had surprisingly little impact on this statistic. Many studies have therefore focused on patient factors such as psychological conditions and socioeconomic factors which appear to have as much, if not more, impact on patient satisfaction than the traditional implant design and technique factors.”
Factors in Play
Postoperative kinesiophobia, a fear of moving1, is relatively common among some orthopedic patients and can lead to disuse of the affected limb. In one study on the use of cognitive behavioral therapy2 for kinesiophobia, the authors found that four individually tailored sessions with a physiotherapist and psychologist resulted in significantly better improvements in scores on the Tampa Scale of Kinesiophobia.
Another complicating factor is central sensitization, which is “not defined by activation of a single molecular pathway but rather represents the altered functional status of nociceptive neurons. During central sensitization, these neurons display one or all of the following: 1) development of or an increase in spontaneous activity; 2) reduction in threshold for activation; and 3) enlargement of nociceptive neuron receptive fields.3”
And you thought orthopedics was just about orthopedics!
The authors found that the use of duloxetine to treat central sensitization “may help to diminish the negative impact of these preoperative comorbidities. It is important to note, however, that outside the realm of TKA, cognitive-behavioral therapy has been recognized as a more effective treatment for central sensitization than medical treatment.”
The current study found that kinesiophobia, central sensitization, depression, anxiety, and pain catastrophizing had a significant association with worse functional outcomes, Patient Reported Outcome Measures, and satisfaction, as well as with an increased risk of pain and complications after TKA.
“The implications are numerous,” added Dr. Barrack to OTW. “Any algorithm to predict patient satisfaction must factor in patient psychological and socioeconomic factors.”
“A major issue in the future will be evaluation of patients for the presence of these conditions, determining if interventions can help improve prospects for patient satisfaction with any of these conditions, and at a minimum improve informed consent to let patients with these conditions know that they have a higher risk of being dissatisfied and possibly even of having complications following TKA.” — EH
References:
- https://www.professionalptandtraining.com/what-is-kinesiophobia/
- https://pubmed.ncbi.nlm.nih.gov/29239772/
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2750819/
