The Journal of Bone and Joint Surgery (American) 86:2179-2186 (2004)
© 2004 The Journal of Bone and Joint Surgery, Inc.
Predicting the Outcome of Total Knee Arthroplasty
Elizabeth A. Lingard, BPhty, MPhil, MPH1,
Jeffrey N. Katz, MD, MS2,
Elizabeth A. Wright, PhD2,
Clement B. Sledge, MD2 and
the Kinemax Outcomes Group*
1 School of Surgical and Reproductive Sciences, The Medical School, University
of Newcastle upon Tyne NE2 4HH, England. E-mail address:
liz.lingard{at}nuth.northy.nhs.uk
2 Robert B. Brigham Arthritis and Musculoskeletal Research Center (J.N.K. and
E.A.W.) and Department of Orthopaedic Research (C.B.S.), Brigham and Women's
Hospital, 75 Francis Street, Boston, MA 02115
Investigation performed at Brigham and Women's Hospital, Boston,
Massachusetts
In support of their research or preparation of this manuscript, one or more
of the authors received grants or outside funding from Stryker Howmedica. In
addition, one or more of the authors received payments or other benefits or a
commitment or agreement to provide such benefits from a commercial entity.
Also, a commercial entity (Stryker Howmedica) paid or directed, or agreed to
pay or direct, benefits to a research fund, foundation, educational
institution, or other charitable or nonprofit organization with which the
authors are affiliated or associated.
* Kinemax Outcomes Group includes: William Gillespie, Colin Howie, Ian Annan,
Alastair Gibson, and Judith Lane (Princess Margaret Rose Hospital, Edinburgh,
Scotland); Ian Pinder, David Weir, Nigel Brewster, and Karen Bettinson
(Freeman Hospital, Newcastle upon Tyne, England); Maurice Needhoff and Roz
Jackson (King's Mill Centre, Mansfield, England); Tim Wilton and Peter Howard
(Derbyshire Royal Infirmary, Derby, England); Ian Forster, Paul Szyprt, Chris
Moran, David Whitaker, Mike Bullock, and Zena Hinchcliffe; (Queen's Medical
Centre, Nottingham, England); Ian Learmonth, John Newman, Chris Ackroyd,
George Langkamer, Robert Spencer, Mark Shannon, Evert Smith, John Dixon, and
Sarah Whitehouse (Avon Orthopedic Centre, Bristol, England); Clement Sledge,
Frederick Ewald, Robert Poss, John Wright, Scott Martin, John Kwon, and Yvette
Valderamma (Brigham and Women's Hospital, Boston, Massachusetts); Steven
Harwin and Michael Lichardi (Beth Israel Medical Center, New York, NY); Mark
Mehlhoff, Linda Weiler, and Tom Cahalan (Physician's Clinic of Iowa, Cedar
Rapids, Iowa); Richard Cronk and Allyson Sandago (Neuromuscular and Joint
Center, Corvallis, Oregon); Stephen Rackemann and Emma McLaughlin (The Knee
Centre, Gold Coast, Queensland, Australia); and Peter Lewis, Robert Bauze,
Gordon Morrison, Tom Stevenson, and Jane Stirling (Queen Elizabeth Hospital,
Adelaide, South Australia, Australia).
Background: The relief of pain and the restoration of functional
activities are the main outcomes of primary total knee arthroplasty for the
treatment of osteoarthritis. This paper examines the preoperative predictors
of pain and functional outcome at one and two years following total knee
arthroplasty.
Methods: Patients were recruited for a prospective observational
study of primary total knee arthroplasty for the treatment of osteoarthritis
from centers in the United States, the United Kingdom, and Australia. Research
assistants recruited the patients and collected the clinical history and
physical examination data preoperatively and at three, twelve, and twenty-four
months postoperatively. The Western Ontario and McMaster University
Osteoarthritis Index (WOMAC), Short Form-36 (SF-36), and demographic data were
obtained by self-administered patient questionnaires.
Results: We recruited 860 patients and obtained one-year WOMAC data
on 759 patients (88%) and two-year data on 701 (82%). The mean age was seventy
years, and 59% of the patients were female. Using hierarchical regression
models, we found that the most significant preoperative predictors of worse
scores on the pain and function domains of the WOMAC scale and on the physical
functioning domain of the SF-36 at one and two years postoperatively were low
preoperative scores, a higher number of comorbid conditions, and a low SF-36
mental health score. After adjusting for these predictors, we found that the
functional status of the patients from the United Kingdom was significantly
worse than that of the patients from the other countries and the difference
was clinically important at both the one-year and two-year follow-up
examination (p < 0.0005). The mean WOMAC pain scores for the three
countries were not significantly different at one year, and, although they
were significantly different at two years (p = 0.025), the difference was not
clinically important.
Conclusions: Patients who have marked functional limitation, severe
pain, low mental health score, and other comorbid conditions before total knee
arthroplasty are more likely to have a worse outcome at one year and two years
postoperatively. After adjusting for these predictors, it was found that
patients from the United Kingdom had significantly worse functional outcomes
but similar pain relief compared with those from the United States and
Australia.
Level of Evidence: Prognostic study, Level I-1
(prospective study). See Instructions to Authors for a complete description of
levels of evidence.
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