Total knee arthroplasty among working-age patients
Hylkema, Tjerk
DOI:
10.33612/diss.136229323
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Publication date: 2020
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Hylkema, T. (2020). Total knee arthroplasty among working-age patients. University of Groningen. https://doi.org/10.33612/diss.136229323
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General introduction
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Osteoarthritis is the most common joint disorder in the world. In Western populations it is one of the most frequent causes of pain, loss of function and reduced quality of life [1]. While osteoarthritis affects almost any joint, primary knee osteoarthritis is one of the most prevalent types [1]. Risk factors for developing knee osteoarthritis include increasing age, obesity, female gender, genetic predisposition, occupational activity and previous knee injury [2-6]. Knee osteoarthritis is usually treated in a stepped-care pathway. In principle, the first step in treatment is offered to all patients but may also be provided through self-care, and includes education, lifestyle advice and acetaminophen. The second step consists of exercise therapy, dietary therapy and non-steroidal anti-inflammatory drugs (NSAIDs). The third step treatment option includes multidisciplinary care, intra-articular injections and/or transcutaneous electrical nerve stimulation, and can be considered for persons with persisting complaints [7]. When these steps do not result in less pain and better functioning, total knee arthroplasty (TKA) is a highly effective treatment for end-stage knee osteoarthritis [7,8]. TKA is successful in reducing knee-specific pain and improving function and health-related quality of life [8]. The first total knee prosthesis was placed in the late 1960s after years of developing materials and techniques. By innovating over the years, with new designs and better fixation methods, long-term results improved in terms of prosthetic survival rates. Nowadays, rates of 94% after ten years are reached with good functional results [1].
Increasing incidence of TKA procedures
In recent years the number of TKA procedures has rapidly risen in Western societies. In the Netherlands 20,605 knee replacement procedures were performed in 2010, and by 2018 this number had reached 25,569 [9]. It is expected that TKA procedures will increase by 297% to 57,900 procedures by 2030 [10]. In the United States, an increase of 673% in knee replacement procedures is expected between 2010 and 2030 [11,12]. Persons of working age in particular represent an increasing proportion those receiving TKA [13]. These rising numbers are the result of an ageing population, the obesity epidemic, a more physically active population with more sports-related knee injuries, and higher retirement age [2,13]. Technically speaking, prostheses
11 have longer survivorships, therefore orthopedic surgeons are able and willing to perform surgery on younger patients [1].
Working-age patients undergoing TKA
For orthopedic surgeons, working-age persons are a relatively new group of patients. TKA used to be primarily performed on senior patients and, accordingly, orthopedic literature only focused on them. Older individuals were opting for TKA to maintain their quality of life by alleviating pain and improving function, despite their age and comorbidities [1]. Although the working-age population is scarcely studied, it is known that working patients have high expectations of TKA beyond pain relief and improved quality of life [14,15]. They want and need to participate in work again, and expect to join in leisure-time activities and do sports again. When deciding for surgery, work participation generally appears more relevant than leisure-time activities [15]. Meeting these patient expectations is of the utmost importance for their satisfaction after TKA.
Work participation
Due to the increased number of working patients receiving TKA, the ability to participate in work is becoming increasingly important as a measure of success [16]. Work is a key aspect of participation and a major determinant of health and well-being [17]. Work helps us build confidence and self-esteem, and rewards us financially. The benefits of a timely return to employment are reported in terms of benefits to both physical and mental health as well as socio-economic factors [17]. Optimizing employment outcomes for this expanding group of patients therefore has health, social and economic benefits for both patients and society. Basically, return to work involves two important outcomes: first patients need to return to work, then they need to experience good work functioning. Both outcomes will be discussed in the following sections.
Return to work
Several studies have examined return to work after TKA and found that return to work rates vary between 41 and 68% in the first year after
TKA[18-1
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21]. This divergence may be attributed to differences per country due to varying work practices, retirement ages, welfare, social and health care, pension arrangements and cultural attitudes toward work [21]. However, these numbers also imply that a substantial proportion of patients do not return to work – minimally 3 out of 10. Studies used to primarily focus on preoperative patient characteristics associated with return to work (yes/no). Two systematic reviews concluded that being female, age <50 years, self-employment, better mental and physical health, and fewer comorbidities were facilitating factors for return to work [18,22]. Work-related knee symptoms and longer preoperative sick leave were associated with no return to work [22]. Based on a longitudinal survey study focusing on the timing of return to work, patients’ personal sense of urgency about returning to work appeared to be an important predictor of faster return to work, irrespective of financial or social motivation or of whether they were self-employed [23]. The aforementioned studies illustrate how a diversity of factors play a role in the return-to-work process after TKA, and are still not completely understood.
Work functioning after returning to work
Being back at work does not necessarily imply that patients are experiencing good work functioning again. Hence it is important to focus not only on return to work but also on performance at work. In order to assess how workers perform their tasks after returning to work given their physical health and mental problems, the concept of work functioning was developed in the late 1990s [24-26]. Work functioning reflects the interplay between work and health, and can be seen as a continuum [24,26,27]. On the one end of the continuum a worker is able to meet all work demands without difficulties given their health status (experiencing difficulties 0% of the time). On the other end of the continuum a worker is no longer able to meet the job’s demands (experiencing difficulties 100% of the time) and does not perform well at all [26]. Workers whose performance is lower than expected, for example because of the aforementioned limitations, are working while sick (presenteeism). Presenteeism entails high societal costs, sometimes even higher than for those who are on sick leave (absenteeism) [28]. In a
13 pilot study among Dutch patients who returned to work after surgery we observed that almost 40% of patients experienced low work functioning [29]. A Canadian study showed that TKA patients experienced fewer limitations at work compared to the presurgical state. Patients nonetheless still reported ongoing difficulties with kneeling, clambering, crouching, operating a motor vehicle, getting to and from work, moving around the workplace, pace of work and sitting for long periods. They also reported difficulties with mental tasks such as meeting job demands, working hours and concentration [30]. To make TKA a success for the working population it is crucial that healthcare professionals support sustained good work functioning. This could start as early as during the preparation before surgery and in particular during recovery from the surgery.
Recovery and work participation after TKA
Recovery after TKA traditionally focuses on pain and stiffness reduction, range of motion improvement and muscle strengthening [31]. For working patients, recovery should also facilitate activity performance and participation in daily life, including work. An important part of recovery takes place in the first three months after surgery [32], but other aspects of recovery, such as return to work, seem to need more time and therefore take place later. Understanding how recovery develops is thus critical to identifying targets for treatment and optimizing return-to-work outcomes. The postsurgical recovery process should therefore be preferably evaluated using multiple follow-up moments to capture all recovery events. It also asks for a comprehensive picture of the working-age patient. Recent studies have shown that improvements in pain and function after TKA by themselves cannot explain working patients’ experience of recovery, and were not the only factors that hindered return to work either, as a high influence of biopsychosocial factors was reported [30,33].
To obtain a more complete picture of a working-age patient receiving TKA it is important for research to go beyond examining solely physical symptoms, by using a biopsychosocial approach [30,33,34]. William Osler (1848-1919) already noted that “it is much more important to know what sort
of a patient has the disease, than to know what disease the patient has” [35].
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The International Classification of Functioning, Disability and Health model (ICF) can be used to examine outcomes of TKA and prognostic factors for outcome from a biopsychosocial perspective. The ICF model was designed by the World Health Organization in 2001 [36], and provides a widely used framework.
The ICF model
The ICF model is an integrative model for describing human functioning and the impact of health applied to health conditions – in this thesis TKA – and functioning captured through the domains of body structure and function, activity and participation, considering the person’s social and physical environment. An overarching term for impairments in body structure or function, activity limitations and participation restrictions is disability. Impairments are problems in body function or structures such as pain or stiffness. Activity limitations are difficulties an individual may have in executing physical or other activities. Participation restrictions are problems an individual may experience in daily life situations, including social and professional contexts. Personal (individual health status, family, friends) or environmental (living situation, type of work, employer) factors may facilitate or hinder performance across ICF domains [36,37].
Figure 1 illustrates the ICF model for TKA patients, presenting the outcome measures used in this thesis to capture the domains. The selection of outcome measures and classification in the ICF model was guided by a previous study that examined the discriminant validity of commonly used TKA outcome measures with ICF constructs [37]. Box 1 describes the use of the ICF model in evaluating functioning of a working-age patient after TKA.
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Figure 1. The ICF model including the outcome measures used in this thesis.
FFiigguurree 11 The ICF model.
TToottaall KKnneeee AArrtthhrrooppllaassttyy
AAccttiivviittiieess
Activity limitations:
- physical functioning BBooddyy FFuunnccttiioonnss && SSttrruuccttuurreess
Physical and mental impairments: - pain - stiffness - vitality - mental health - depressive symptoms PPaarrttiicciippaattiioonn Participation restrictions: - social functioning - work functioning - return to work PPeerrssoonnaall ffaaccttoorrss - age - gender - education level - body mass index - comorbidity - pain catastrophizing
EEnnvviirroonnmmeennttaall ffaaccttoorrss - home situation - being the wage earner - working hours - job type
(physical/non-physical) - type of employment (employee or self-employed)
Box 1. The value of using the ICF model in the context of TKA can be illustrated
by taking the example of a regular TKA patient. Mrs. De Boer, age 60, had primary knee osteoarthritis for several years already. She works as clerical support staff, mainly doing desk and computer work. She underwent TKA successfully about half a year ago, yet is still having problems sitting for long periods. The physical
impairments for Mrs. De Boer include pain during kneeling and ongoing stiffness.
She is also experiencing activity limitations in daily life, such as going to the toilet, cleaning the house, and picking up things from the floor. Her knee problems result in participation restrictions. Although she has returned to work, Mrs. De Boer is still working fewer hours per week and is experiencing reduced work functioning, as she needs to sit for long stretches at the workplace. If asked for, her husband helps her clean the house (personal factor), but unfortunately her employer does not facilitate a sit-stand desk (environmental factor).
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Until now, benefits of TKA among working-age patients have been primarily quantified using measures that evaluated the ICF domains body functions (mainly pain) and function in day-to-day activities. Regarding the domain
participation, previous literature focused on daily life in general or
return-to-work outcome. Little attention has been paid to work functioning that patients experience after return to work, and measures like postoperative absenteeism or presenteeism have not been examined. To optimize outcomes of TKA among working-age patients it is crucial to explore all ICF domains and understand how personal and environmental factors affect domains during recovery. In essence, this is what motivated the research in this thesis.
Aims of this thesis
The overall aim of this thesis was to expand our knowledge of working-age patients receiving TKA, from their preoperative state to postoperative outcomes using a biopsychosocial approach. The specific research aims were:
· to gain a more profound insight into the preoperative characteristics of working-age TKA patients;
· to examine the recovery process with special attention to work participation, including return to work and work functioning; · to explore objectively measured sedentary and physical activity
behaviors.
Outline of the thesis
Chapter 2 describes the preoperative characteristics of working-age patients
planned for TKA. Preoperative characteristics were subsequently compared with senior TKA candidates (age >65) and with normative values from a general population. Chapter 3 aimed to identify the recovery courses after
TKA from a biopsychosocial approach. The ICF model was used to describe physical and mental impairments, activity limitations and participation restrictions in a longitudinal design among working patients. Prognostic personal and environmental factors for better recovery courses were examined. Chapter 4 analyzed the recovery courses of TKA patients who
17 individual recovery courses of physical and mental impairments, activity limitations and participation restrictions, again in line with the ICF model.
Chapter 5 examined a TKA patient population living in the United States.
We identified how these patients perform at their job after return to work. Several work-related outcomes were examined in terms of absenteeism, presenteeism and at-work productivity loss. Besides work-related outcomes, activity impairments during activities outside work were explored. Patient characteristics associated with worse outcomes were also identified.
Chapter 6 presents objectively gathered sedentary and physical activity
data of working TKA patients during a week, also taking occupational and leisure time into account. Compensation effects of sedentary and physical activity behavior between occupational and leisure time were analyzed. Finally, Chapter 7 presents the general discussion. The main findings of
this thesis are discussed, methodological considerations are addressed, and recommendations for research and practice are presented.
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