Total joint arthroplasties: Current concepts of patient outcomes after surgery

Focus of outcome research for total joint arthroplasties has been directed toward understanding the surgical and technical aspects. More recent evaluations of total joint arthroplasties have used patient-centered outcomes. The lack of success reported by some patients can be attributed to surgical-related factors or complications, but in others, no specific reason can be identified. Little is known about the causal inferences of clinical variables on these outcomes; however, several patient characteristics may, indeed, affect the pain and functional outcomes after total joint arthroplasties. The role that comorbid conditions exert on pain and functional outcomes is not clearly defined. The effect of comorbid conditions as they relate to pain and functional outcomes requires further examination. Standardized measures of comorbid conditions are typically weighted with respect to mortality, an infrequent endpoint in total joint arthroplasty surgery. If specific comorbidities and patientrelated factors that affect pain and functional recovery can be readily identified, orthopaedic surgeons and clinicians would then be able to present evidence-based risks to patients during preoperative planning stages. Because little is known about the type of comorbid conditions and other patient-related factors that affect outcomes after total joint arthroplasty, indications and contraindications are poorly defined and utilization rates vary among geographic regions. The relationship between psychosocial variables and pain and functional outcomes is one of particular interest because so little investigation has explored this plausible model. It is known that patients with high levels of anxiety or depression tend to have a worse outcome; however, the extent to which it affects their understanding and expectations about the surgery and behaviors in relation to recovery, rehabilitation, and return to their usual daily activities has yet to be ascertained. With an aging population that is expected to live a longer and more active life, coupled with increasing technical and surgical advancements the demand for total joint arthroplasties will increase. Inasmuch as these procedures have a positive outcome on most patients' function and HQRL, younger patients with arthritis are receiving total joint arthroplasties. This demographic subgroup will likely continue to increase. To date, we have relatively little information regarding long-term patient outcome and prosthesis survivorship in these more active patients. Further work is required to determine implant longevity and subsequent outcomes following revision surgery in young patients. Improvement seen with pain and function after total joint arthroplasties, for the most part, remains unexplained by clinical factors. No one patient-related or perioperative factor that is available to the orthopaedic surgeon or clinician can clearly predict the amount of pain relief or functional improvement. A myriad of factors most likely affect the outcomes of pain and function. Most arthroplasties are appropriately performed because the majority of patients improve, but health status data available to surgeons and clinicians are not helpful in identifying those patients who will not improve. For more explicit answers to emerge, alternative factors such as psychosocial factors and patient expectations need to be examined to provide further insights into the determinants of pain and functional outcomes of total joint arthroplasties.