1. Unhappy patient Following a Total knee

2. Summary Incidence Incidence Aetiology Aetiology Diagnosis Diagnosis Prevention Prevention

3. Historically 11%-18% not satisfied with TKR Scott C et al. Predicting dissatisfaction following total knee replacement 2010; JBJS 92-B, 9, 1253-1258. Scott C et al. Predicting dissatisfaction following total knee replacement 2010; JBJS 92-B, 9, 1253-1258. 1 Year: 18.6% not satisfied 1 Year: 18.6% not satisfied Patient expectation Patient expectation mental component score, depression and pain in other joints mental component score, depression and pain in other joints Bourne et al patient satisfaction after TKR. CORR 2010,468:57-63 Bourne et al patient satisfaction after TKR. CORR 2010,468:57-63 Ontario 1703 primary TKR (2001-2005) Ontario 1703 primary TKR (2001-2005) 19% Not Satisfied 19% Not Satisfied Main predictor is patient expectations Main predictor is patient expectations

4. Painful TKR Intrinsic Infection Infection Mal-alignment Mal-alignment Wear Wear Instability Instability Lysis Lysis Instability Instability Coronal Coronal saggital saggital Loosening Loosening Soft-tissue impingement Patellar clunk Fabellar impingement Popliteus tendon impingement Component overhang

5. Extensor mechanism problems Patellar maltracking Extensor mechanism disruption (patellar fracture, patellar tendon rupture, quadricep tendon rupture) Undersized patellar button with lateral facet impingement Oversized patellar button with overstuffing of patellofemoral joint Patella baja + alta

6. Painful TKR Extrinsic Hip pathology Spinal disorders Complex regional pain syndrome Psychological disorder Outcome expectation mismatch

7. Diagnosis History History Pain from start Pain from start Examination Examination Xray Xray Bloods Bloods CT Scan CT Scan Nicoll D, Rowley DI. J Bone Joint Surg Br. 2010 Sep;92(9):1238-44 Nicoll D, Rowley DI. J Bone Joint Surg Br. 2010 Sep;92(9):1238-44 56% of painful TKR had internal rotation errors 56% of painful TKR had internal rotation errors Arthroscopy Arthroscopy

8. Prevention Choose surgeon Choose surgeon Infection, mal-alignment, instability, loosening, mal-rotation Infection, mal-alignment, instability, loosening, mal-rotation Choose patient Choose patient Choose prosthesis Choose prosthesis

9. Infection (21%-38%)

10. Mal-alignment

11. S Johnstone 2/4/9 Done 2005

12. S Johnst

13. SJ 7/8/09

14. E M 30/9/04 Massive posterior slope and varus cut

15. E.M 15/7/9 5/11/2010

16. 2009 Instability 2004Wear

17. Wear Lysis

18. Wear

19. Loosening

20. Extensor mechanism Patella tracking

21. 2006 2009 Extensor mechanism Patella Fracture

22. other 14/8/06 5/2/07 15/01/08

23. 1/4/09

24. Choose patient Amin et al. J Bone Joint Surg Br. 2006 Oct;88(10):1321-6 Amin et al. J Bone Joint Surg Br. 2006 Oct;88(10):1321-6 A higher rate of complications 32%

25. Patient Expectation Ghandi R et al. J Arthroplasty. 2009 Aug;24(5):716- 21. Patient expectations predict greater pain relief with joint arthroplasty. Ghandi R et al. J Arthroplasty. 2009 Aug;24(5):716- 21. Patient expectations predict greater pain relief with joint arthroplasty. a greater expectation of pain relief with surgery independently predicted greater reported pain relief at 1 year of follow-up a greater expectation of pain relief with surgery independently predicted greater reported pain relief at 1 year of follow-up Singh JA, et al. Pessimistic explanatory style: a psychological risk factor for poor pain and functional outcomes two years after knee replacement. J Bone Joint Surg [Br] 2010;92-B:799–806. Singh JA, et al. Pessimistic explanatory style: a psychological risk factor for poor pain and functional outcomes two years after knee replacement. J Bone Joint Surg [Br] 2010;92-B:799–806.

26. Patient outcome expectation mismatch