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J Knee Surg
DOI: 10.1055/a-2607-9835
Original Article

What Matters Most for Patient Satisfaction Following Total Knee Arthroplasty? A Prospective Institutional Assessment of Individual Questions Captured by KOOS and VR-12 Mental Composite Score

Ahmed K. Emara
1   Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
,
Brian Benyamini
2   Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
,
Ignacio Pasqualini
1   Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
,
Alvaro Ibaseta 
1   Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
,
Alison K. Klika
1   Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
,
Shujaa T. Khan
1   Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
,
Cleveland Clinic Adult Reconstruction Research,
Nicolas S. Piuzzi 
1   Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
› Author Affiliations
Funding None.
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Abstract

Patient-reported outcome measures (PROMs) are crucial in evaluating the success of primary total knee arthroplasty (TKA). This study aimed to determine the individual significance of each question of the Knee Osteoarthritis Outcome Score (KOOS) and the Veterans RAND 12 (VR-12) Mental Composite Score (MCS) in achieving a Patient Acceptable Symptom State (PASS).

A prospectively collected cohort of 9,942 unilateral elective TKAs was analyzed. Responses were collected for 17 KOOS questions (KOOS-Pain subscore, KOOS-Physical Function Short form [PS], and KOOS-Joint related [JR]) and 6 MCS questions preoperatively and 1-year postoperatively. Achievement of PASS was assessed through a positive response to a binary satisfaction-related question. The association between responses to questions and outcomes was examined via multivariable logistic regression models.

A poorer preoperative response to knee pain frequency (odds ratio [OR] = 0.86 [0.77–0.97], p = 0.017) and knee pain while sitting or lying (OR = 0.88 [0.79–0.99], p = 0.029) was independently associated with reduced odds of achieving PASS at 1-year post-TKA. A more favorable preoperative response in knee pain during full knee straightening was independently associated with an increased odds of PASS attainment (OR = 1.10 [1.01–1.19], p = 0.035). No other metric was independently associated with PASS attainment at 1 year.

Individual KOOS questions evaluating knee pain frequency, knee pain while sitting or lying down, and knee pain during full knee straightening were linked to patient satisfaction 1 year following TKA. Patients experiencing frequent or persistent knee pain at rest may represent those with more advanced joint disease or heightened pain sensitivity, contributing to lower postoperative satisfaction. Conversely, patients reporting minimal or no pain during specific movements, such as full knee straightening, likely had a less severe baseline condition, making their postoperative expectations more easily attainable, thereby leading to higher satisfaction.

Level of evidence III.

Keywords

total knee arthroplasty - KOOS - PASS - TKA - Knee Injury and Osteoarthritis Outcome Score

* Cleveland Clinic Adult Reconstruction Research consists of Chao Zhang, MS3 Yuxuan Jin, MS3 Trevor G. Murray, MD1 Robert M. Molloy, MD1 Kim L. Stearns, MD1 Viktor E. Krebs, MD1 Michael R. Bloomfield, MD1 John P. McLaughlin, MD1 Matthew E. Deren, MD1 Peter Surace, MD1 Wael K. Barsoum, MD1




Publication History

Received: 20 August 2024

Accepted: 13 May 2025

Accepted Manuscript online:
14 May 2025

Article published online:
30 May 2025

© 2025. Thieme. All rights reserved.

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  • References

  • 1 Roos EM, Toksvig-Larsen S. Knee injury and Osteoarthritis Outcome Score (KOOS) - validation and comparison to the WOMAC in total knee replacement. Health Qual Life Outcomes 2003; 1: 17
    CrossrefPubMedSearch in Google Scholar
  • 2 Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD. Knee Injury and Osteoarthritis Outcome Score (KOOS)–development of a self-administered outcome measure. J Orthop Sports Phys Ther 1998; 28 (02) 88-96
    CrossrefPubMedSearch in Google Scholar
  • 3 Orr MN, Klika AK, Gagnier JJ, Bhandari M, Piuzzi NS. A call for a standardized approach to reporting patient-reported outcome measures: Clinical relevance ratio. J Bone Joint Surg Am 2021; 103 (22) e91
    CrossrefPubMedSearch in Google Scholar
  • 4 Pasqualini I, Piuzzi NS. New CMS policy on the mandatory collection of patient-reported outcome measures for total hip and knee arthroplasty by 2027: What orthopaedic surgeons should know. J Bone Joint Surg Am 2024; 106 (13) 1233-1241
    CrossrefPubMedSearch in Google Scholar
  • 5 Pasqualini I, Rullán PJ, Huffman N. et al. Challenging the status quo: Debunking the necessity of 5-year to 10-year patient-reported outcome measures in total hip and knee arthroplasties. J Arthroplasty 2024; 39 (9S2): S143-S150
    PubMedSearch in Google Scholar
  • 6 Pasqualini I, Piuzzi NS. Patient-reported outcome measures: State of the art in patient-reported outcome measure application in lower extremity orthopaedics. J Am Acad Orthop Surg 2023; 31 (20) e883-e889
    PubMedSearch in Google Scholar
  • 7 Kvien TK, Heiberg T, Hagen KB. Minimal clinically important improvement/difference (MCII/MCID) and patient acceptable symptom state (PASS): What do these concepts mean?. Ann Rheum Dis 2007; 66 (Suppl. 03) iii40-iii41
    PubMedSearch in Google Scholar
  • 8 Wells G, Beaton D, Shea B. et al. Minimal clinically important differences: Review of methods. J Rheumatol 2001; 28 (02) 406-412
    PubMedSearch in Google Scholar
  • 9 Sedaghat AR. Understanding the minimal clinically important difference (MCID) of patient-reported outcome measures. Otolaryngol Head Neck Surg 2019; 161 (04) 551-560
    CrossrefPubMedSearch in Google Scholar
  • 10 Glassman SD, Copay AG, Berven SH, Polly DW, Subach BR, Carreon LY. Defining substantial clinical benefit following lumbar spine arthrodesis. J Bone Joint Surg Am 2008; 90 (09) 1839-1847
    PubMedSearch in Google Scholar
  • 11 Goh GS, Baker CM, Tarabichi S, Clark SC, Austin MS, Lonner JH. The paradox of patient-reported outcome measures: Should we prioritize “feeling better” or “feeling good” after total knee arthroplasty?. J Arthroplasty 2022; 37 (09) 1751-1758
    PubMedSearch in Google Scholar
  • 12 Pasqualini I, Mariorenzi M, Klika AK. et al. Establishing patient-centered metrics for the knee injury and osteoarthritis outcome score following medial unicompartmental knee arthroplasty. Knee 2024; 46: 1-7
    PubMedSearch in Google Scholar
  • 13 Tubach F, Ravaud P, Baron G. et al. Evaluation of clinically relevant states in patient-reported outcomes in knee and hip osteoarthritis: The patient acceptable symptom state. Ann Rheum Dis 2005; 64 (01) 34-37
    CrossrefPubMedSearch in Google Scholar
  • 14 Wiering B, de Boer D, Delnoij D. Meeting patient expectations: patient expectations and recovery after hip or knee surgery. Musculoskelet Surg 2018; 102 (03) 231-240
    PubMedSearch in Google Scholar
  • 15 Randall E, Bryan S, Black C, Goldsmith LJ. What matters to patients following total knee arthroplasty? A grounded theory of adapting to a knee replacement. BMC Musculoskelet Disord 2022; 23 (01) 845
    PubMedSearch in Google Scholar
  • 16 Shah HN, Barrett AA, Le PH, Arora P, Kamal RN, Amanatullah DF. Lack of alignment between orthopaedic surgeon priorities and patient expectations in total joint arthroplasty. Patient Saf Surg 2023; 17 (01) 17
    PubMedSearch in Google Scholar
  • 17 Dahm DL, Barnes SA, Harrington JR, Sayeed SA, Berry DJ. Patient-reported activity level after total knee arthroplasty. J Arthroplasty 2008; 23 (03) 401-407
    PubMedSearch in Google Scholar
  • 18 Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KDJ. Patient satisfaction after total knee arthroplasty: Who is satisfied and who is not?. Clin Orthop Relat Res 2010; 468 (01) 57-63
    CrossrefPubMedSearch in Google Scholar
  • 19 Kazis LE, Miller DR, Skinner KM. et al. Patient-reported measures of health: The Veterans Health Study. J Ambul Care Manage 2004; 27 (01) 70-83
    CrossrefPubMedSearch in Google Scholar
  • 20 Curtis GL, Tariq MB, Brigati DP, Faour M, Higuera CA. Cleveland Clinic Orthopaedic Arthroplasty Group. Validation of a novel surgical data capturing system following total hip arthroplasty. J Arthroplasty 2018; 33 (11) 3479-3483
    CrossrefPubMedSearch in Google Scholar
  • 21 OME Cleveland Clinic Orthopaedics. Implementing a scientifically valid, cost-effective, and scalable data collection system at point of care: The Cleveland Clinic OME Cohort. J Bone Joint Surg Am 2019; 101 (05) 458-464
    CrossrefPubMedSearch in Google Scholar
  • 22 Rullán PJ, Pasqualini I, Zhang C, Klika AK, Piuzzi NS. The Cleveland Clinic OME Arthroplasty Group. How to raise the bar in the capture of patient-reported outcome measures in total joint arthroplasty: Results from active and passive follow-up measures. J Bone Joint Surg Am 2024; 106 (10) 879-890
    CrossrefPubMedSearch in Google Scholar
  • 23 Emara AK, Pasqualini I, Jin Y. et al.; the Cleveland Clinic Arthroplasty Group. Diagnosis-specific thresholds of the minimal clinically important difference and patient acceptable symptom state for KOOS after total knee arthroplasty. J Bone Joint Surg Am 2024; 106 (09) 793-800
    PubMedSearch in Google Scholar
  • 24 Nembrini S, König IR, Wright MN. The revival of the Gini importance?. Bioinformatics 2018; 34 (21) 3711-3718
    PubMedSearch in Google Scholar
  • 25 Minator Sajjadi M, Keyhani S, Kazemi SM, Hanafizadeh B, Ebrahimpour A, Banasiri M. Patient satisfaction following total knee arthroplasty: Comparison of short-term results in rheumatoid arthritis and osteoarthritis. Arch Bone Jt Surg 2019; 7 (01) 61-66
    PubMedSearch in Google Scholar
  • 26 Dekhne MS, Fontana MA, Pandey S. et al. Defining patient-relevant thresholds and change scores for the HOOS JR and KOOS JR anchored on the patient-acceptable symptom state question. Clin Orthop Relat Res 2024; 482 (04) 688-698
    PubMedSearch in Google Scholar
  • 27 Scott CEH, Howie CR, MacDonald D, Biant LC. Predicting dissatisfaction following total knee replacement: A prospective study of 1217 patients. J Bone Joint Surg Br 2010; 92 (09) 1253-1258
    CrossrefPubMedSearch in Google Scholar
  • 28 Hamilton DF, Lane JV, Gaston P. et al. What determines patient satisfaction with surgery? A prospective cohort study of 4709 patients following total joint replacement. BMJ Open 2013; 3 (04) e002525
    CrossrefPubMedSearch in Google Scholar
  • 29 Baker PN, van der Meulen JH, Lewsey J, Gregg PJ. National Joint Registry for England and Wales, Data from the National Joint Registry for England and Wales. The role of pain and function in determining patient satisfaction after total knee replacement. J Bone Joint Surg Br 2007; 89 (07) 893-900
    CrossrefPubMedSearch in Google Scholar
  • 30 Judge A, Arden NK, Kiran A. et al. Interpretation of patient-reported outcomes for hip and knee replacement surgery: identification of thresholds associated with satisfaction with surgery. J Bone Joint Surg Br 2012; 94 (03) 412-418
    CrossrefPubMedSearch in Google Scholar
  • 31 Gandhi R, Davey JR, Mahomed NN. Predicting patient dissatisfaction following joint replacement surgery. J Rheumatol 2008; 35 (12) 2415-2418
    PubMedSearch in Google Scholar
  • 32 Orr MN, Klika AK, Emara AK, Piuzzi NS. Cleveland Clinic Arthroplasty Group. Combinations of preoperative patient-reported outcome measure phenotype (pain, function, and mental health) predict outcome after total knee arthroplasty. J Arthroplasty 2022; 37 (6S): S110-S120 , 120.e5
    CrossrefPubMedSearch in Google Scholar
  • 33 Kahlenberg CA, Nwachukwu BU, McLawhorn AS, Cross MB, Cornell CN, Padgett DE. Patient satisfaction after total knee replacement: A systematic review. HSS J 2018; 14 (02) 192-201
    CrossrefPubMedSearch in Google Scholar
  • 34 Bryan S, Goldsmith LJ, Davis JC. et al. Revisiting patient satisfaction following total knee arthroplasty: A longitudinal observational study. BMC Musculoskelet Disord 2018; 19 (01) 423
    CrossrefPubMedSearch in Google Scholar
  • 35 Adie S, Harris I, Chuan A, Lewis P, Naylor JM. Selecting and optimising patients for total knee arthroplasty. Med J Aust 2019; 210 (03) 135-141
    PubMedSearch in Google Scholar