Accepted Manuscript

Physical health problems experienced in the early postoperative recovery periodfollowing total knee replacement

Kirsten Szöts, Preben U. Pedersen, Britta Hørdam, Thordis Thomsen, HanneKonradsen

PII: S1878-1241(14)00031-8DOI: http://dx.doi.org/10.1016/j.ijotn.2014.03.005Reference: IJOTN 203

To appear in: International Journal of Orthopaedic and TraumaNursing

Please cite this article as: K. Szöts, P.U. Pedersen, B. Hørdam, T. Thomsen, H. Konradsen, Physical health problemsexperienced in the early postoperative recovery period following total knee replacement, International Journal ofOrthopaedic and Trauma Nursing (2014), doi: http://dx.doi.org/10.1016/j.ijotn.2014.03.005

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PHYSICAL HEALTH PROBLEMS EXPERIENCED IN THE EARLY

POSTOPERATIVE RECOVERY PERIOD FOLLOWING TOTAL KNEE

REPLACEMENT

Kirsten Szöts, MScN. 1*, Preben U. Pedersen, professor, Ph.D. 2, Britta Hørdam, RN, MScN, Ph.D.

3, Thordis Thomsen, RN, Ph.D. 4 & Hanne Konradsen, Research manager, Ph.D. 5

1 Orthopaedic Department, Gentofte University Hospital, DK

2 Centre for Clinical Guidelines, Department of Health Science and Technology, Aalborg

University, Denmark

3 University College Sealand, Denmark

4 Abdominal Centre, Rigshospitalet, Denmark & Clinical Health Promotion Centre, Faculty of

Medicine, Lund University, Sweden

5

Research Unit, Gentofte University Hospital, Denmark

* Corresponding author: Kirsten Szöts, E-mail adress: kirsten.szoets@regionh.dk

ABSTRACT

Background: The length of stay in hospital following total knee replacement is markedly shortened

due to fast-track program and the patients have to be responsible for the recovery at a very early

stage. The aim of this study was to investigate the prevalence of physical health problems and the

level of exercising in the early recovery period after discharge from hospital following total knee

replacement.

Method: A cross-sectional survey was conducted using a questionnaire. In total 86 patients were

included following first-time elective total knee replacement. Descriptive statistics were used.

Results: The majority of the patients experienced leg-oedema (90.7%). Secondly were pain

(81.4%), sleeping disorders (47.7%) problems with appetite (38.4%) and bowel function (34.9 %)

the most frequently identified physical health problems. In total 69.8 % of the patients indicated that

they did not or partly exercise as recommended, but without association to experience of pain.

Conclusion: Patients experienced a wide range of physical health problems following total knee

replacement and deviation from recommended self-training was identified. These findings are

valuable for health professionals in regard to improve treatment as well as patient education and

information.

KEYWORDS: Total knee replacement, physical health problems, post-surgery

INTRODUCTION

The number of patients who need knee replacement has increased during the last decade. It is

estimated that 1,4 million knee replacement procedures will be performed in 2015 worldwide

(Sorci, 2012). In Denmark approximately 9000 procedures are performed annually (Danish Knee

Arthroplasty Register, 2012). The main clinical indication for total knee replacement (TKR) is

osteoarthritis (Carr , Robertsson, Graves et al., 2012) causing severe pain and substantial functional

disabilities, leading to a decrease in health-related quality of life (Ethgen, Bruyere, Richy et al.,

2004). The mean age for Danish patients who require TKR is 67 years. Twenty-two percent of the

patients are younger than 60 years old and 59 % are females (Danish Knee Arthroplasty Register,

2012). The surgical intervention is a common procedure, which despite low level of mortality and

complications entails a severe surgical trauma and a protracted recovery (Salmon, Hall, Peerbhoy et

al, 2001). Three to six months after TKR physical health status is markedly better for the majority

of patients compared to the preoperative level (Ethgen, Bruyere, Richy et al., 2004)

In Denmark the implementation of fast-track programs for surgical procedures has reduced the

length of stay in hospital following TKR from around 11 to 4 days from 2000 to 2009 (Husted,

Jensen, Solgaard et al., 2012). The length of stay is now 3 days in several surgical centres (Kehlet

& Soballe, 2010) with an actual intention of reducing length of stay to 1-2 days (Husted, Jensen,

Solgaard et al., 2012).

Fast track program

Principles of fast track recovery program for TKR are based on perioperative care, multimodal pain

treatment, aggressive postoperative rehabilitation including early mobilization and early oral

nutrition (Husted & Holm, 2006), and motivation of patients to be active participants (Husted

2012).

The Department of Orthopaedic Surgery at Gentofte University Hospital is a specialized ward for

patients receiving knee or hip replacement. In total 632 primary TKR procedures were performed in

2011 (Danish Knee Arthroplasty Register, 2012). Due to implementation of the fast track program

TKR patients are admitted to the ward on the day of surgery or the evening before due to long-range

transport. All preparatory examinations and tests are performed in the outpatient clinic.

Furthermore, patients attend to a multidisciplinary education seminar before admission. The

seminar is conducted by a surgeon, an anaesthesiologist, a physiotherapist, an occupational

therapist, and a nurse. The seminar is focused on the surgical intervention, anaesthetization,

possible complications and risks, pain treatment, the admission course and expected length of stay,

introduction to physical exercise training, and equipment.

Discharge from hospital is scheduled 2-3 days post-surgery. Patients are referred to physiotherapy

in the community setting and instructed to complete a self-training program until they start

physiotherapy. Removal of stitches or staples is conducted by their general practitioner. One

outpatient consultations by the surgeon is scheduled 3 months post-surgery.

BACKGROUND

Due to the shortened length of stay in hospital, patients have to take responsibility for their own

rehabilitation following TKR at a very early stage. Hereby patients are faced with the realities of

caring for themselves or being cared for by their relatives during recovery.

Studies have mainly focused on the outcome following TKR in regard to pain, physical function

and performance, activity in daily living and health related quality of life from the time of discharge

from hospital up to several years postoperative (Bachmeier, March, Cross et al., 2001; Heiberg,

Bruun-Olsen, & Mengshoel, 2010; Kennedy, Hanna, Stratford, et al., 2006; Kennedy, Stratford,

Hanna et al., 2006; Stevens-Lapsley, Schenkman, & Dayton, 2011; Wylde, Dixon, & Blom, 2012;

Yoshida, Mizner, Ramsey et al., 2008), and the degree of fatigue and mood has also been elucidated

(Salmon, Hall, Peerbhoy et al, 2001).

During rehabilitation following TKR patients experienced unexpected challenges, which they felt

inadequately prepared for, e.g. pain intensity and management, sleep disturbance, psychological

issues, activity, length of recovery and fatigue (Gustafsson, Ponzer, Heikkila et al., 2007;

Marcinkowski, Wong, & Dignam, 2005; Westby & Backman, 2010). Furthermore unclear and

unrealistic expectations were seen as a reason for more pain, anxiety, insecurity and depression

besides disappointment and impatience in the recovery period (Showalter, Burger, & Salyer, 2000;

Westby & Backman, 2010).

Empirical studies identifying physical health problems experienced by the patients in the early

recovery period following TKR are few. One study examined the reasons for continued post-

surgery hospitalization in TKR fast track program (Husted, Lunn, Troelsen et al., 2011) and

identified primarily pain, dizziness and general weakness but also nausea, vomiting and sedation as

reasons for not being discharged to home earlier.

The first month after TKR, the patients´ primary concern after discharge from hospital is related to

body function (Rastogi, Chesworth, & Davis, 2008). Pain management and bowel function were

identified as the stressors of most concern 7 days after discharge (Barksdale & Backer, 2005), and

hampered mobility was identified as the main symptom leading to distress 4 weeks postoperatively

(Sveinsdottir & Skuladottir, 2012). However, no study has examined the prevalence of physical

health problems in the early rehabilitation period following TKR after discharge to home.

Postoperative exercise is a highly prioritized part of the treatment post-surgery to preserve knee

extension strength following TKR and thereby maximize the outcome of the surgical intervention

(Societas Ortopaedica Danica, 2004). The level of self-training may be influenced by physical

symptoms experienced after discharge to home. However, we lack knowledge of the patients´

compliance with the recommended self-training program.

The aim of this study was to investigate the prevalence of physical health problems and the level of

self-training in the early recovery period after discharge following TKR.

METHOD

This study was conducted from May to September 2011 at the Department of Orthopaedic Surgery,

Gentofte University Hospital in Denmark.

Design

A cross-sectional design was chosen for its advantages for exploratory research, as this is the best

method to determine prevalence when gathering data from a large number of subjects (Carlson &

Morrison, 2009; Mann, 2003). This design involves collection of data only one time and this kind of

study is appropriate for describing the status of phenomena or for describing a relationships among

phenomena at a fixed point of time (Polit & Beck, 2008)

Participants

Participants were consecutively enrolled in the study during admission if they met the inclusion

criteria and none of the exclusion criteria. The inclusion criteria were as follows: having undergone

an elective first-time primary total knee replacement, over 18 years old, able to read and talk

Danish, discharged to home and referred to physiotherapy in the community. On the assumption

that frequent contact to health professionals might influence the number of experienced physical

symptoms, patients were excluded if they received nursing care at home, lived in a nursing home,

were readmitted to hospital before the interview or had psychiatric diagnosis listed in the medical

record. Furthermore, patients were excluded if they were unable to give consent.

All patients were discharged to their home according to the following criteria: able to manage

personal hygiene by themselves, to walk with one or two crutches, and to climb stairs. Before

discharge from the hospital the first author made an appointment for a telephone interview.

During the 5 months study period, 102 patients were admitted for first-time primary TKR. No

patients rejected to participate in the study. Two patients were not able to give consent. In total 13

patients were excluded as two patients were not reachable by phone, six patients were readmitted,

four patients received nursing care at home and one patient had physiotherapy at the hospital. One

patient withdrew consent after discharge from hospital. In total 86 patients were included of which

59.3 % (N=51) were women. Further characteristics of the participants are described in Table 1.

Data collection

A questionnaire survey was conducted by telephone. Patients were contacted 2-3 weeks after

discharge from hospital. The questionnaire was developed by Hørdam (Hørdam, Sabroe, Pedersen

et al., 2010) based on inspiration of an American study (Savage & Grap, 1999) and previously used

to identify patients´ perception of their current situation after a total hip replacement. The

questionnaire encompasses the following 7 items to assess the experience of physical health-related

problems: leg-oedema, pain, sleep disturbance, problems with appetite, dizziness, nausea, problems

urinating and problems with bowel function. The questions were answered with yes or no. If

experience of pain was identified, patients were asked to rate level of pain using the Numerical

Rating Scale from 0 (no pain at all) to 10 (the worst imaginable pain). Finally, patients were given

the opportunity to identify any additional symptoms they had experienced. When assessing patients’

level of exercising, the possibilities for answering were: as recommended, partly as recommended

or not exercising. Patients were asked to answer all the questions from their experience in the last 3

days.

All interviews were conducted by the first author, who entered the verbal responses to a paper

version of the used questionnaire.

Analysis

Data were analysed using SPSS Version 19.0 (SPSS Inc., Chicago, IL, USA) to report distribution

ratios. A confidence interval of 95% (CI) was calculated for further specification of the result and to

enable comparisons of the present findings with the findings of other studies.

For analysis of association between categorical variables the chi-square test was used. In order to

analyse for differences related to numerical variable within and between groups one-way ANOVA

was carried out.

RESULTS

The frequency of identified physical health problems are presented in Table 2. Symptoms such as

leg-oedema and pain were experienced by 90.7% (n=78) and 81.4% (n=70) patients respectively.

Secondly sleeping disorders, problems with appetite and bowel function were identified as the most

dominating physical health problems. Physical health problems not specified in the questionnaire

were identified by 25.6% (N=22) of patients. One of these patients identified two physical health

problems while the other patients identified one. These problems were: fatigue, wound problems,

sedative symptoms, discoloration of the knee, the actual function of the knee, sequelae from the use

of tourniquet cuff per-operatively, and headache.

In total 94.3% (n=66) of patients experiencing pain were able to specify a NRS pain score with a

mean-score of 5.56 (range 3-10; SD 1.86) and 45.6 % (N=31) of these patients scored their pain

level > 5.

Furthermore, 69.8 % (n=60) of patients indicated that they did not exercise or only partly exercised

as recommended. Patients not exercising were instructed to immobilize the operated knee due to

suspicion of infection. The distribution of level of exercising is presented in Table 3. An one-way

ANOVA analysis of the relation between level of exercising and the actual pain score indicated no

difference between groups (p= 0.368).

Between 2 and 5 physical health problems were identified by 81.4% (n=78) of patients, while only

3.5% (n=3) of patients experienced no physical health problems at all. Table 4 shows the

distribution of the numbers of the experienced physical health problems.

The mean number of experienced physical health problems was similar for the group of patients

who exercised as recommended (mean 3.18; SD 1.59; SEM 0.30) compared to the group who

exercised partly as recommended or not at all (mean 3.63; SD 1.50; SEM 0.20). No correlation

between the number of physical health problems and level of exercising was found (p = 0.201).

A significant correlation between specific health problems and exercising partly as recommended

was only identified in regard to problems with urinating (p = 0.042). See table 5.

DISCUSSION

To our knowledge this is the first study exploring the prevalence of physical symptoms and level of

exercising after discharge from TKR. A variety of physical health problems and impaired

compliance with the recommended self-training program were identified.

Early intensive mobilization and physiotherapy is important to avoid complications such as

prolonged stiffness and delay in recovery of strength of the knee (Holm, Kristensen, Myhrmann, et

al., 2010). Pain is considered the most important limiting factor for physical training of the knee

post-surgery. In our study no association was found between the experience of pain and the level of

exercising. However, the level of exercising does not clarify the intensity of the actual performance

of the exercises, and the intensity of exercising is considered of importance to the outcome of the

surgical intervention as well (Holm, Kristensen, Myhrmann et al., 2010). Compliance to exercise

programs for adults with osteoarthritis is seen as a general problem influenced by contact to

physiotherapist (de Jong, Hopman-Rock, Tak et al., 2004). After ended contact to physiotherapist

the level of compliance decreases over time. Compliance to exercise programs is influenced by the

individually lived life comprising the individual perception of disease, treatment, and effect of

exercising as well as integration of exercising into everyday life (Campbell, Evans, Tucker et al.,

2001). All these aspects might influence the level of exercising after discharge from TKR as well.

TKR is categorized as major surgery (Salmon, Hall, Peerbhoy et al, 2001) causing physiological

stress (Hall, Peerbhoy, Shenkin et al., 2000). Opioid analgesics are the cornerstone after orthopaedic

surgery (Pizzi, Toner, Foley et al., 2012), though minimization of opioid intake post-surgery is one

of the strategies of the TKR fast track program (Kehlet & Soballe, 2010). The consequences of the

surgical intervention and postoperative pain treatment are multiple (Benyamin, Trescot, Detta et al.,

2008). In the present study we identified a relatively high prevalence of physical symptoms that

may be related to the surgical trauma as well as to the pain treatment.

The identification of leg-oedemas as a frequent physical health problem was expected. Swelling of

the knee is a common response to the surgical intervention, but the degree of oedema is of

importance for the function of the knee and the functional performance following TKR (Holm,

Kristensen, Bencke et al., 2010).

A study of the pattern of pain following TKR documented significant pain (a pain score > 40 at the

Visual Analogue Scale; 0 = no pain, 100 = intolerable pain) 1 month post-surgery (Brander,

Stulberg, Adams et al., 2003). Therefore the fact that 81.4 % of patients experienced pain two to

three weeks post-surgery was anticipated. However, optimization of pain relief in order to

maximize early mobilization and physiotherapy as well as decreased length of stay in hospital has

been one of the main goals for the recovery program following TKR (Holm, Kristensen,

Myhrmann, et al., 2010). In our study, 45.6 % of patients had an overall NRS pain score > 5. This

does not meet the recommendations for pain treatment in the fast track program for TKR (NRS

score ≤ five in activity and ≤ 3 when inactive), but no relation between pain intensity and level of

exercising was found. However, it should be noted that the NRS pain score in this study was a

general assessment of the level of pain during the day with no distinction between level of activity

and without relation to the compliance with the prescribed analgesic medicine.

The experience of sleep disturbance and problems with appetite is in accordance with results from

other studies focusing on objective measures of sleep and nutrition following TKR. After discharge

from hospital following total hip and knee replacement night-time sleep duration decreased 6 days

post-surgery compared to prior to surgery (Krenk, Jennum, & Kehlet, 2013). Patients identified

decreased function of the affected joint as a hindering factor for their movement as the main reason

for sleep disturbance. No association between pain and sleep was identified (Krenk, Jennum, &

Kehlet, 2013). Likewise affected nutrition has been identified following TKR in patients with

osteoarthritis as the energy intake 10 days post-surgery decreased to 80 % of the intake before

surgery (Haugen, Homme, Reigstad et al., 1999).

The identification of problems with appetite and bowel function as well as dizziness, nausea,

problems with urination, fatigue, sedative symptoms and headache may be opioid-related adverse

effects. In this study the frequency of problems with bowel function (34.9 %) and dizziness (17.4%)

is higher compared to the frequency during hospitalization in orthopaedic patients treated with

opioid post-surgery (26 % and 11% respectively) (Pizzi, Toner, Foley et al., 2012). In contrast

nausea was identified more frequently (30%) as an adverse effect during hospitalization than in this

study (16.3%). These differences can be due to the pattern of response to opioid intake over time,

the immediate guidance and possibility of additional medication during hospitalization and

discontinuation of opioid intake after discharge to home. In accordance with the findings in our

study fatigue following TKR has been identified several weeks post-surgery and was significantly

improved one month post-surgery compared to preoperative level (Salmon, Hall, Peerbhoy et al,

2001). However, experience of fatigue following major joint surgery cannot be explained

physiologically and focus on psychological aspects is recommended (Hall & Salmon, 2002).

A significant correlation between exercising partly as recommended was only identified in regard to

problems with urination. The explanation behind this finding is not obvious and need further

exploration.

In total 25,6% of patients experienced physical symptoms, which were not predefined in the

questionnaire. These findings may not reflect the actual number or the variety of additional physical

health problems following TKR, because some surgical patients may not present all their physical

health problems due to an assumption that some problems are too insignificant (Barksdale &

Backer, 2005). An expansion of used questionnaire is relevant for a further clarification of the

frequency of physical health problems experienced post TKR to provide a more detailed insight to

patients´ experiences.

The participants represent a mean age and distribution of gender that correspond to Danish TKR-

patients as described earlier. However, the survey was conducted in a single hospital and may

reflect the experience of physical health problems resulting from the practice of this specific

hospital. Furthermore, we did not record data concerning comorbidities, the use of analgesics or

other medication, non-pharmacologic pain management, and use of urinary catheter during

hospitalization. All factors which might affect experience of physical health problems and level of

exercising limiting the generalization of the findings.

When the small sample size is taken into account this study must be considered as a pilot study

contributing to a clarification of the kind and extent of problems, which TKR-patients experience

after discharge from hospital. Furthermore, the focus was isolated to physical aspects of the

recovery period without attention to psychosocial aspects, which might influence the recovery

period as well.

CONCLUSION

This study is a snap shot of the early recovery period after discharge from TKR providing evidence

for a broad variation of physical health problems, which TKR patients face in the early recovery

period after discharge from hospital. Motivation of patients to be active participants is prioritized in

fast track programs, which requires involvement of the patient. The identification of several

physical health problems frequently experienced in the early recovery period after discharge can

support development of targeted and effective patient education supporting patients´ ability of self-

care after discharge from hospital.

The results indicate a future challenge in regard to optimization of pain management without

compromising physical recovery. Furthermore, additional explorations of TKR-patients´ physical

and psychosocial experiences in the recovery after discharge as well as prospective interventional

studies are needed to improve recovery following TKR.

REFERENCES

Bachmeier, C. J., March, L. M., Cross, M. J., Lapsley, H. M., Tribe, K. L., Courtenay, B. G., &

Brooks, P. M. (2001). A comparison of outcomes in osteoarthritis patients undergoing total

hip and knee replacement surgery. Osteoarthritis Cartilage, 9(2), 137-146.

Barksdale, P., & Backer, J. (2005). Health-related stressors experienced by patients who underwent

total knee replacement seven days after being discharged home. OrthopaedicNursing, 24(5),

336-342.

Benyamin, R., Trescot, A. M., Datta, S., Buenaventura, R., Adlaka, R., Sehgal, N.,Glaser, S. &

Vallejo, R. (2008). Opioid complications and side effects. Pain Physician, 11,Suppl 2, 105-

120.

Brander, V. A., Stulberg, S. D., Adams, A. D., Harden, R. N., Bruehl, S., Stanos, S. P., & Houle, T.

(2003). Predicting total knee replacement pain: A prospective, observational study. Clinical

Orthopaedics and Related Research, (416), 27-36.

Campbell, R., Evans, M., Tucker, M., Quilty, B., Dieppe, P., & Donovan, J. L. (2001). Why don't

patients do their exercises? Understanding non-compliance with physiotherapy in patients

with osteoarthritis of the knee. Journal of Epidemiology & Community Health, 55(2), 132-

138.

Carlson, M. D., & Morrison, R. S. (2009). Study design, precision, and validity in observational

studies. Journal of Palliatiative Medicine, 12(1), 77-82.

Carr, A. J., Robertsson, O., Graves, S., Price, A. J., Arden, N. K., Judge, A., & Beard, D. J. (2012).

Knee replacement. Lancet, 379(9823), 1331-1340.

de Jong, O. R., Hopman-Rock, M., Tak, E. C., & Klazinga, N. S. (2004). An implementation study

of two evidence-based exercise and health education programmes for older adults with

osteoarthritis of the knee and hip. Health Education Research, 19(3), 316-325.

Danish Knee Arthroplasty Register, 2012.

http://www.knee.dk/groups/dkr/pdf/DKRrapport2012.pdf.

Ethgen, O., Bruyere, O., Richy, F., Dardennes, C., & Reginster, J. Y. (2004). Health-related quality

of life in total hip and total knee arthroplasty. A qualitative and systematic review of the

literature. Journal of Bone and Joint Surgery, American volume, 86-A(5), 963-974.

Gustafsson, B. A., Ponzer, S., Heikkila, K., & Ekman, S. L. (2007). The lived body and the

perioperative period in replacement surgery: Older people's experiences. Journal of

Advanced Nursing, 60(1), 20-28.

Hall, G. M., Peerbhoy, D., Shenkin, A., Parker, C. J., & Salmon, P. (2000). Hip and knee

arthroplasty: A comparison and the endocrine, metabolic and inflammatory responses.

Clinical Science, 98(1), 71-79.

Hall, G. M., & Salmon, P. (2002). Physiological and psychological influences on postoperative

fatigue. Anesthesia & Analgesia, 95(5), 1446-1450.

Haugen, M., Homme, K. A., Reigstad, A., & Teigland, J. (1999). Assessment of nutritional status in

patients with rheumatoid arthritis and osteoarthritis undergoing joint replacement surgery.

Arthritis Care and Research, 12(1), 26-32.

Heiberg, K., Bruun-Olsen, V., & Mengshoel, A. M. (2010). Pain and recovery of physical

functioning nine months after total knee arthroplasty. Journal of Rehabilitation Medicine,

42(7), 614-619.

Holm, B., Kristensen, M. T., Bencke, J., Husted, H., Kehlet, H., & Bandholm, T. (2010). Loss of

knee-extension strength is related to knee swelling after total knee arthroplasty. Archives of

Physical Medicine and Rehabilitation, 91(11), 1770-1776.

Holm, B., Kristensen, M. T., Myhrmann, L., Husted, H., Andersen, L. O., Kristensen, B., & Kehlet,

H. (2010). The role of pain for early rehabilitation in fast track total knee arthroplasty.

Disabilities and Rehabilitation, 32(4), 300-306.

Husted, H. (2012). Fast-track hip and knee arthroplasty: clinincal and organizational aspects. Acta

Orthopaedica Supp., 83(346), 1-39.

Husted, H., & Holm, G. (2006). Fast track in total hip and knee arthroplasty - experiences from

Hvidovre University Hospital, Denmark. Injury, 37 Suppl 5, 31-35.

Husted, H., Jensen, C. M., Solgaard, S., & Kehlet, H. (2012). Reduced length of stay following hip

and knee arthroplasty in denmark 2000-2009: From research to implementation. Archives of

Orthopaedic and Trauma Surgery, 132(1), 101-104.

Husted, H., Lunn, T. H., Troelsen, A., Gaarn-Larsen, L., Kristensen, B. B., & Kehlet, H. (2011).

Why still in hospital after fast-track hip and knee arthroplasty? Acta Orthopaedica, 82(6),

679-684.

Hørdam, B., Sabroe, S., Pedersen, P. U., Mejdahl, S., & Soballe, K. (2010). Nursing intervention by

telephone interviews of patients aged over 65 years after total hip replacement improves

health status: A randomised clinical trial. Scandinvian Journal of Caring Science, 24(1), 94-

100.

Kehlet, H., & Soballe, K. (2010). Fast-track hip and knee replacement--what are the issues? Acta

Orthopaedica, 81(3), 271-272.

Kennedy, D. M., Hanna, S. E., Stratford, P. W., Wessel, J., & Gollish, J. D. (2006). Preoperative

function and gender predict pattern of functional recovery after hip and knee arthroplasty.

Journal of Arthroplasty, 21(4), 559-566.

Kennedy, D. M., Stratford, P. W., Hanna, S. E., Wessel, J., & Gollish, J. D. (2006). Modeling early

recovery of physical function following hip and knee arthroplasty. BMC Musculoskelet

Disorders, 7, 100.

Krenk, L., Jennum, P., & Kehlet, H. (2013). Activity, sleep and cognition after fast-track hip or

knee arthroplasty. Journal of Arthroplasty, 28(8), 1265-1269.

Mann, C. J. (2003). Observational research methods. Research design II: Cohort, cross sectional,

and case-control studies. Emergency Medicine Journal, 20(1), 54-60.

Marcinkowski, K., Wong, V. G., & Dignam, D. (2005). Getting back to the future: A grounded

theory study of the patient perspective of total knee joint arthroplasty. Orthopaedic Nursing,

24(3), 202-209.

Pizzi, L. T., Toner, R., Foley, K., Thomson, E., Chow, W., Kim, M., Couto, J., Royo, M. & Viscusi,

E. (2012). Relationship between potential opioid-related adverse effects and hospital length

of stay in patients receiving opioids after orthopedic surgery. Pharmacotherapy, 32(6), 502-

514.

Polit, D., & Beck, C. (2008). Nursing Research. Generating and Assessing Evidence for Nursing

Practice, 8th Edition. Lippincott Williams & Wilkins. pp 195-218

Rastogi, R., Chesworth, B. M., & Davis, A. M. (2008). Change in patient concerns following total

knee arthroplasty described with the international classification of functioning, disability

and health: A repeated measures design. Health and Quality of Life Outcomes, 6, 112.

Salmon, P., Hall, G. M., Peerbhoy, D., Shenkin, A., & Parker, C. (2001). Recovery from hip and

knee arthroplasty: Patients' perspective on pain, function, quality of life, and well-being up

to 6 months postoperatively. Archives of Physical Medicine and Rehabilitation, 82(3), 360-

366.

Savage, L. S., & Grap, M. J. (1999). Telephone monitoring after early discharge for cardiac surgery

patients. American Journal of Critical Care, 8(3), 154-159.

Showalter, A., Burger, S., & Salyer, J. (2000). Patients' and their spouses' needs after total joint

arthroplasty: A pilot study. Orthopaedic Nursing, 19(1), 49-57, 62.

Societas Ortopaedica Danica (2004). DOS referenceprogram. Knænær osteotomi og primær

knæalloplastik

Available at: http://www.ortopaedi.dk/fileadmin/referenceprogram/Doc00000048.pdf.

Sorci, R. (2012). Increasing incidence of joint replacements burdens healthcare systems.

Available at:http://www.nerac.com/search.php?keyword=replacement&term=&type=library

Stevens-Lapsley, J. E., Schenkman, M. L., & Dayton, M. R. (2011). Comparison of self-reported

knee injury and osteoarthritis outcome score to performance measures in patients after total

knee arthroplasty. PM R: The Journal of Injury, Function, and Rehabiliation, 3(6), 541-549.

Sveinsdottir, H., & Skuladottir, H. (2012). Postoperative psychological distress in patients having

total hip or knee replacements: An exploratory panel study. Orthopaedic Nursing, 31(5),

302-311.

Westby, M. D., & Backman, C. L. (2010). Patient and health professional views on rehabilitation

practices and outcomes following total hip and knee arthroplasty for osteoarthritis:A focus

group study. BMC Health Services Research, 10, 119.

Wylde, V., Dixon, S., & Blom, A. W. (2012). The role of preoperative self-efficacy in predicting

outcome after total knee replacement. Musculoskeletal Care, 10(2), 110-118.

Yoshida, Y., Mizner, R. L., Ramsey, D. K., & Snyder-Mackler, L. (2008). Examining outcomes

from total knee arthroplasty and the relationship between quadriceps strength and knee

function over time. Clinical Biomechanism, 23(3), 320-328.

Table 1. Characteristics of the participants.

Mean Min-max SD

Age 67,2 34 – 89 11,1

Length of stay (days) 4,1 3-7 1,0

Time for contact

(days after discharge)

17,5 16-20 1,4

Time for contact

(days after surgery)

20,6 18-26 0,9

Table 2. Frequency of physical health problems identified 2-3 weeks after discharge following TKR.

Note: a) 3 patients identified this as habitual problem. b) 6 patients identified this as habitual problem.

Symptoms N % CI 95%

Identified by asking of experience of the specific symptom

Leg-oedema

78 a

90,7

84,6 – 96,8

Pain 70 81,4 73,2 – 89,6

Sleep disturbance 41 a 47,7 37,1 – 58,3

Problems with appetite 33 38,4 28,1 – 48,7

Problems with bowel function 30 34,9 24,8 – 45,0

Dizziness 15 17,4 9,4 – 25,4

Nausea 14 16,3 8,7 – 24,5

Problems urination 12 b 14,0 6,7 – 21,3

Identified by asking of any additional experienced problems

Fatigue

7

8,1

2,3 – 13,9

Wound problems 6 7,0 1,6 – 12,4

Sedative symptoms 4 4,7 0,2 – 9,2

Discoloration of knee 3 3,5 0 - 7,4

Sequelae from tourniquet cuff 2 2,3 0 - 5,5

Headache 1 1,2 0 – 3,5

Table 3. Distribution of level of exercising 2-3 weeks after discharge following TKR related to recommendations for

self-training.

Level of exercising N % CI 95%

No exercising

4

4,7%

0,2 – 9,2

Partly as recommended 56 65,1% 55,0 – 75,2

As recommended 23 26,7% 17,3 – 36,1

Not able to answer 3 3,5 %

Table 4. Distribution of number of physical health problems experienced by the individual patients 2-3 weeks after

discharge following TKR.

Number of problems N % CI 95%

0

3

(3.5 %)

0 – 7,4

1 3 (3.5 %) 0 – 7,4

2 16 (18.6 %) 10,4 – 26,8

3 24 (28.0 %) 18,5 – 37,5

4 16 (18.6 %) 10,4 – 26,8

5 14 (16.3 %) 8,5 – 24,1

6 8 (9.3 %) 3,2 – 15,4

7 2 (2.3 %) 0 – 5,5

Note: The number of problems identified as habitual is not included in the table.

Table 5. The significance of association between partly exercising and specific physical health problem experienced 2-3

weeks post discharge following TKR.

Symptoms identified by asking

of experience of the specific

symptom

Level of significance

(p)

Leg-oedema 0.250

Pain 0.200

Sleep disturbance 0.350

Problems with appetite 0.344

Problems with bowel function 0.528

Dizziness 0.060

Nausea 0.468

Problems with urination 0.042*

* p < 0.05

CONFLICT OF INTEREST STATEMENT

The authors have no conflicts of interest.

ETHICAL STATEMENT

The study was submitted to The Regional Committee on Health Research Ethics and approval was

not required to initiate this cross sectional study (no. H-4-2011-FSP (43)). The Danish Protection

Agency has approved the trial (no. 2007-58-015).

The trial was conducted according to the latest Declaration of Helsinki (World Medical Association,

2008). All eligible patients were informed about the trial verbally and in writing and all the

participants signed written informed consent forms. They were informed that they could withdraw

at any time. All data were handled with confidentiality, and the patients were ensured anonymity.

ROLE OF FUNDING SOURCE

The authors received no funding for this article.