Audiovisual information in patients undergoing a total knee replacement. Is it important to modify preoperative expectations?

Osteoarthritis of the knee is one of the most prevalent pathologies in our society. After many years studying this pathology, surgical treatment is seen as most appropriate in patients with pain, limitation of function and loss of quality of life [1], Lingard EA, Sledge CB, Learmonth ID (2006) Patient expectations regarding total knee arthroplasty: differences among United States, United Kingdom and Australia. J Bone Joint Surg Am 88:1201-1207.[2], Mancuso CA, Sculco TP, Wickiewicz TL, Jones EC, Robbins L, et al (2001) Patients’ expectations of knee surgery. J Bone Joint Surg Am 83:1005-1012.[3] Noble PC, Conditt MA, Cook KF, Mathis KB (2006) Patient expectations affect satisfaction with total knee arthroplasty. Clin Orthop Relat Res 452: 35-43..

The main goal for the surgeon, subsequent to any surgical treatment, is to achieve maximum patient satisfaction with regard to the surgery performed.

Total knee replacement (TKR) is probably the best solution to solve the clinical symptoms of this pathology in its advanced stages. However, the result in this type of treatment is usually influenced by multiple factors that the surgeon does initially not control.

One of these factors is the expectation that patient has created around the outcome after arthroplasty [4] Leal-Blanquet J, Alentorn-Geli E, Ginés-Cespedosa A, Martínez-Díaz S, Cáceres E, et al (2013) Effects of an educational audiovisual videodisc on patients’ pre-operative expectations with total knee arthroplasty: a prospective randomized comparative study. Knee Surg Sports Traumatol Arthrosc 21: 2595-2602..

This expectation is formed and conditioned by the information that the patient receives before and after the visit with the surgeon [5] Redman RW, Lynn MR (2005) Assesment of patient expectations for care. Res Theory Nurs Pract 19: 275-285.. The result of the creation of the preoperative expectation will influence postoperative patient satisfaction. The higher the coincidence between preoperative expectation and the real final result as perceived by the patient, the greater the postoperative satisfaction [6], Mancuso CA, Salvati EA, Johnson NA, Peterson MGE, Charlson ME, et al (1997) Patient’s expectations and satisfaction with total hip arthroplasty. J Arthroplasty 12: 387-396.[7], McGregor AH, Hughes S (2002) The evaluation of the surgical management of nerve root compression in patients with low back pain. Part 2: Patient expectations and satisfaction. Spine 27: 1471-1476.[8] Nilsdoter AK, Toksvig-Larsen S, Roos EM (2009) Knee arthroplasty: are patient’ espectations fulfilled? A prospective study of pain and function in 102 patients with 5 years follow-up. Acta Orthopaedica 80: 55-61..

This leads us to see at it a triangle with three vertices made up by information, expectation and satisfaction. The correct information must be provided in order to generate realistic expectations that lead to maximum postoperative satisfaction.

This triangle theory is very attractive, but it will not work in all our patients. The main reason for this ineffectiveness will be weighty external influences that the social environment can have on this person. The role that family and friends and even Internet have on the patient may create unrealistic expectations that will affect satisfaction and the final real result [5] Redman RW, Lynn MR (2005) Assesment of patient expectations for care. Res Theory Nurs Pract 19: 275-285..

For all these reasons, the key element of the triangle is information sharing to foster realistic expectations that lead to full satisfaction. This information can be conveyed in several ways [9] Aydin D, Klit J, Jacobsen S, Troelsen A, Husted H (2015) No major effects of preoperative education in patients undergoing hip or knee replacement – a systematic review. Dan Med J 62(7): 1-5.. The most common and widespread is the classic verbal information. You can also reach the patient in an audiovisual or a written form. They all can be carried out on an individual basis or in groups.

Most articles in the literature agree that classical verbal information sharing is the most effective and even more so if done on an individual basis [4] Leal-Blanquet J, Alentorn-Geli E, Ginés-Cespedosa A, Martínez-Díaz S, Cáceres E, et al (2013) Effects of an educational audiovisual videodisc on patients’ pre-operative expectations with total knee arthroplasty: a prospective randomized comparative study. Knee Surg Sports Traumatol Arthrosc 21: 2595-2602.. It is important to determine what kind of information the patient needs and what expectations are generated at interview time. This is the key moment to temper these expectations and promote better adaptation to the real final result. A more personalized sharing of information that is tailored to the patient’s specific needs may increase the general success of preoperative education [9] Aydin D, Klit J, Jacobsen S, Troelsen A, Husted H (2015) No major effects of preoperative education in patients undergoing hip or knee replacement – a systematic review. Dan Med J 62(7): 1-5..

Knowing that the best method is the personal interview information, other information systems have been postulated as complementary tools to serve as a guide to changing expectations to give the patient a more realistic scenario to assess the future surgical procedure [4] Leal-Blanquet J, Alentorn-Geli E, Ginés-Cespedosa A, Martínez-Díaz S, Cáceres E, et al (2013) Effects of an educational audiovisual videodisc on patients’ pre-operative expectations with total knee arthroplasty: a prospective randomized comparative study. Knee Surg Sports Traumatol Arthrosc 21: 2595-2602..

One of these systems, about which little has been written in the literature, is the audiovisual method. In 2007, our Knee Unit team at Parc de Salut Mar designed a randomized prospective study in which we studied the effect of this system on the change in preoperative expectations in patients undergoing a TKR [4] Leal-Blanquet J, Alentorn-Geli E, Ginés-Cespedosa A, Martínez-Díaz S, Cáceres E, et al (2013) Effects of an educational audiovisual videodisc on patients’ pre-operative expectations with total knee arthroplasty: a prospective randomized comparative study. Knee Surg Sports Traumatol Arthrosc 21: 2595-2602..

Most articles in the literature studied, preoperatively, the influence of the information on the patient's expectation in terms of how this information generates high or low expectations. Postoperatively, the focus of the majority of studies have been on the fulfillment of these expectations and the assessment of final patient satisfaction [1], Lingard EA, Sledge CB, Learmonth ID (2006) Patient expectations regarding total knee arthroplasty: differences among United States, United Kingdom and Australia. J Bone Joint Surg Am 88:1201-1207.[10], Koenen P, Bäthis H, Schneider MM, Fröhlich M, Bouïllon B, et al (2014) How do we face patients’ expectations in joint arthroplasty?. Arch Orthop Trauma Surg. 134: 925-931.[11], Yoo Jh, Chang CB, Kung YG, Kim SJ, Seong SC (2011) Patient expectations of total knee replacement and their association with sociodemographic factors and functional status. J Bone Joint Surg Br. 93(3): 337-344.[12], Gahndi R, Davey JR, Mahomed N (2009) Patient expectations predict greater pain relief with joint arthroplasty. J Arthroplasty 24(5): 716-721.[13], Muniesa JM, Marco E, Tejero M, Boza R, Duarte E , et al (2010) Analysis of the expectations of elderly patients before undergoing total knee replacement. Arch Gerontol Geriatr 51(3): e83-e87.[14] Mancuso CA, Sculco TP, Salvati EA (2003) Patients with poor preoperative functional status have high expectations of total hip arthroplasty. J Arthroplasty 18(7): 872-878..

Our study focuses on the assessment of how an audiovisual system can modify the previous expectations of the patient. This study attempts to verify whether an additional tool along with classical verbal information sharing can affect those expectations in some sense (increase or decrease) [4] Leal-Blanquet J, Alentorn-Geli E, Ginés-Cespedosa A, Martínez-Díaz S, Cáceres E, et al (2013) Effects of an educational audiovisual videodisc on patients’ pre-operative expectations with total knee arthroplasty: a prospective randomized comparative study. Knee Surg Sports Traumatol Arthrosc 21: 2595-2602.. In addition, we attempted to identify the profile of the patient in whom the audiovisual support would be more effective in terms of the modification of expectations. It was considered important to assess whether there is the need to deal with all patients or only part of those whose profile was more suitable to changing expectations with the audiovisual tool. This might help us better define the financial costs of information processing.

In this sense, it is more important to know the quantitative difference between the preoperative expectation score and the expectation score that the patient has after information sharing. This is more important than what most articles cover as more emphasis is placed on the degree of expectation is high or low [10], Koenen P, Bäthis H, Schneider MM, Fröhlich M, Bouïllon B, et al (2014) How do we face patients’ expectations in joint arthroplasty?. Arch Orthop Trauma Surg. 134: 925-931.[11], Yoo Jh, Chang CB, Kung YG, Kim SJ, Seong SC (2011) Patient expectations of total knee replacement and their association with sociodemographic factors and functional status. J Bone Joint Surg Br. 93(3): 337-344.[12], Gahndi R, Davey JR, Mahomed N (2009) Patient expectations predict greater pain relief with joint arthroplasty. J Arthroplasty 24(5): 716-721.[13], Muniesa JM, Marco E, Tejero M, Boza R, Duarte E , et al (2010) Analysis of the expectations of elderly patients before undergoing total knee replacement. Arch Gerontol Geriatr 51(3): e83-e87.[14] Mancuso CA, Sculco TP, Salvati EA (2003) Patients with poor preoperative functional status have high expectations of total hip arthroplasty. J Arthroplasty 18(7): 872-878.. If expectations are not compared before and after information sharing, we cannot know the effect in each person depending on the type of information given.

The main finding of our study was discovering that efficacy in the modification of preoperative expectations by introducing an additional audiovisual method was not demonstrated. We did not find a patient profile in which this method was more effective. After analyzing the Hospital for Special Surgery Knee Replacement Expectations Survey, only two of the questions posed to the patient were changed significantly. They were on range of motion and the use of stairs [4] Leal-Blanquet J, Alentorn-Geli E, Ginés-Cespedosa A, Martínez-Díaz S, Cáceres E, et al (2013) Effects of an educational audiovisual videodisc on patients’ pre-operative expectations with total knee arthroplasty: a prospective randomized comparative study. Knee Surg Sports Traumatol Arthrosc 21: 2595-2602..

In terms of change of expectations, the results of our study are similar to those encountered by other authors [15], Weng HH, Kaplan RM, Boscardin WJ, Maclean CH, Lee IY, et al (2007) Development of a decision aid to address racial disparities in utilization of knee replacement surgery. Arthritis Rheum. 57: 568.[16] Groeneveld PW, Kwoh CK, Mor MK, Appelt CJ, Geng M, et al (2008) Racial differencies in expectations of joint replacement surgery outcomes. Arthritis Rheum. 59(5): 730-737. . However, they found differences related to the race studied and how this difference affects the level of preoperative expectations. These two studies showed that African Americans had lower expectations relative to the results than Caucasian patients. Weng et al, also demonstrated that these African American patients improved their expectations more than Caucasians after information sharing. The reason for this finding is that their initial expectations were lower and this point makes the likelihood of an increase greater. Caucasians had higher expectations and so did not alter (increase) those expectations with audiovisual support [15] Weng HH, Kaplan RM, Boscardin WJ, Maclean CH, Lee IY, et al (2007) Development of a decision aid to address racial disparities in utilization of knee replacement surgery. Arthritis Rheum. 57: 568.. Again, and in the light of these studies, we can say that the importance of preoperative information lies in changing the expectation and not knowing whether they are higher or lower. It is probable that the initial level of expectation depends on the demographics of each patient and not on the information received. However, the information is going to have an effect on those expectations by bringing them in line with the real final result.

Analyzing what the literature says about expectations depending on the patient's profile, we see that the male with more intense preoperative pain, not living alone/being married, poor general sense of well-being and a reduced body mass index (BMI) seem to be associated with high preoperative expectations [12], Gahndi R, Davey JR, Mahomed N (2009) Patient expectations predict greater pain relief with joint arthroplasty. J Arthroplasty 24(5): 716-721.[13], Muniesa JM, Marco E, Tejero M, Boza R, Duarte E , et al (2010) Analysis of the expectations of elderly patients before undergoing total knee replacement. Arch Gerontol Geriatr 51(3): e83-e87.[14] Mancuso CA, Sculco TP, Salvati EA (2003) Patients with poor preoperative functional status have high expectations of total hip arthroplasty. J Arthroplasty 18(7): 872-878.. Other authors demonstrate that living alone and a history of joint arthroplasty were associated with lower expectations and that being male and Caucasian were associated with higher preoperative expectations [17] Hepinsall MS, Ratledge JR, Bornstein LJ, Mazumdar M, Westrich GH (2011) Factors that impact expectations before total knee arthroplasty. 26(6): 870-876. . In our study, in terms of modification of the expectations, no differences were found in terms of demographics (sex, age, weight and BMI), the functional scores (Knee Society Score, Western Ontario & McMaster Universities Osteoarthritis Index and Short Form-36) and radiological characteristics [4] Leal-Blanquet J, Alentorn-Geli E, Ginés-Cespedosa A, Martínez-Díaz S, Cáceres E, et al (2013) Effects of an educational audiovisual videodisc on patients’ pre-operative expectations with total knee arthroplasty: a prospective randomized comparative study. Knee Surg Sports Traumatol Arthrosc 21: 2595-2602..

In the context of the items on the scale of expectations that we used, it seems that some of them can be modified in a significant way with the audiovisual information (range of motion and use of stairs). In any case, the use this additional tool is probably not needed due to the possibility of providing such information through the classical verbal system [4] Leal-Blanquet J, Alentorn-Geli E, Ginés-Cespedosa A, Martínez-Díaz S, Cáceres E, et al (2013) Effects of an educational audiovisual videodisc on patients’ pre-operative expectations with total knee arthroplasty: a prospective randomized comparative study. Knee Surg Sports Traumatol Arthrosc 21: 2595-2602.. This value does not compensate in terms of the cost-effectiveness of this action.

In recent years, there have been some articles that refer to the importance of preoperative information to reduce patient anxiety with regard to the surgical procedure [18], Kearney M, Jennrich MK, Lyons S (2011) Effects of preoperative education on patient autcomes after joint replacement surgery. Orthop Nurs. 30: 391-396.[19] Graudet-LeQuintrec JS, Coste J, Vastel L (2003) Positive effect of patient education for hip surgery: a randomized trial. Clin Orthop Relat Res. 414: 112-120.. However, other studies show that audiovisual information sharing methods improve understanding of the process, reduce the interview time with the patient but do not show differences in the degree of patient anxiety [20] Kakinuma A, Nagatani H, Otake H, Mizuno J, Nakata Y (2011) The effects of short interactive animation video information on preoperative anxiety, knowledge and interview time: a randomized controlled trial. Anesth Analg. 112(6): 1314-1318. .

In summary and in order to clarify the basic concepts related to the triangle of information, expectation and satisfaction, it is important to note that:

1. Patient satisfaction with the surgical process will be essential to achieving good postoperative results [21], Becker R, Doring C, Denecke A, Brosz M (2011) Expectation, satisfaction and clinical outcome of patients after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 19: 1433-1441.[22], Engel C, Hamilton NA, Potter PT, Zaura AJ (2004) Impact of two types of expectancy and recovery from total knee replacement surgery (TKR) in adults with osteoarthritis. Behav Med. 30: 113123.[23] Gonzalez M, Escobar A, Herrera C, Garcia L, Aizpuru F, Sarasqueta C. Patient expectation and health related quality of life outcomes following total joint replacement. Value Health. 2010; 13: 447-454..

2. It is important to note that, although it is not the reason for this article, this patient satisfaction is highly related to compliance with the preoperative expectations [4], Leal-Blanquet J, Alentorn-Geli E, Ginés-Cespedosa A, Martínez-Díaz S, Cáceres E, et al (2013) Effects of an educational audiovisual videodisc on patients’ pre-operative expectations with total knee arthroplasty: a prospective randomized comparative study. Knee Surg Sports Traumatol Arthrosc 21: 2595-2602.[6], Mancuso CA, Salvati EA, Johnson NA, Peterson MGE, Charlson ME, et al (1997) Patient’s expectations and satisfaction with total hip arthroplasty. J Arthroplasty 12: 387-396.[7], McGregor AH, Hughes S (2002) The evaluation of the surgical management of nerve root compression in patients with low back pain. Part 2: Patient expectations and satisfaction. Spine 27: 1471-1476.[8] Nilsdoter AK, Toksvig-Larsen S, Roos EM (2009) Knee arthroplasty: are patient’ espectations fulfilled? A prospective study of pain and function in 102 patients with 5 years follow-up. Acta Orthopaedica 80: 55-61..

3. Adequate information about the surgical process is very important in the doctor-patient relationship and a fantastic tool to modify preoperative expectations and adapt better to the clinical outcome. In turn, this information may counteract unrealistic expectations that the patient may have before the interview with the doctor [4], Leal-Blanquet J, Alentorn-Geli E, Ginés-Cespedosa A, Martínez-Díaz S, Cáceres E, et al (2013) Effects of an educational audiovisual videodisc on patients’ pre-operative expectations with total knee arthroplasty: a prospective randomized comparative study. Knee Surg Sports Traumatol Arthrosc 21: 2595-2602.[23] Gonzalez M, Escobar A, Herrera C, Garcia L, Aizpuru F, Sarasqueta C. Patient expectation and health related quality of life outcomes following total joint replacement. Value Health. 2010; 13: 447-454..

4. Sometimes, the medical interview is not as long as it should be. Then the inclusion of additional strategies in the shape of audiovisual information tool may be appropriate in order to complement this preoperative information [4] Leal-Blanquet J, Alentorn-Geli E, Ginés-Cespedosa A, Martínez-Díaz S, Cáceres E, et al (2013) Effects of an educational audiovisual videodisc on patients’ pre-operative expectations with total knee arthroplasty: a prospective randomized comparative study. Knee Surg Sports Traumatol Arthrosc 21: 2595-2602..

5. Audiovisual information differs from the written information (another possible complement to classical verbal information) in that written information requires some degree of literacy on the part of the patient and may be subject to more subjective interpretations other than what it is intended to convey [4], Leal-Blanquet J, Alentorn-Geli E, Ginés-Cespedosa A, Martínez-Díaz S, Cáceres E, et al (2013) Effects of an educational audiovisual videodisc on patients’ pre-operative expectations with total knee arthroplasty: a prospective randomized comparative study. Knee Surg Sports Traumatol Arthrosc 21: 2595-2602.[24] Kirwanek S, Armbruster C, Beckerhinn P, Blauensteier W, Gschwantler M (1998) Patients’ assessment and recall of surgical information after laparoscopic cholecystectomy. Dig Surg. 15: 669-673. .

6. Good information, whatever the chosen information delivery route, will shape expectations to generate greater postoperative satisfaction and lead to patient satisfaction with the preoperative process, as well [4], Leal-Blanquet J, Alentorn-Geli E, Ginés-Cespedosa A, Martínez-Díaz S, Cáceres E, et al (2013) Effects of an educational audiovisual videodisc on patients’ pre-operative expectations with total knee arthroplasty: a prospective randomized comparative study. Knee Surg Sports Traumatol Arthrosc 21: 2595-2602.[24] Kirwanek S, Armbruster C, Beckerhinn P, Blauensteier W, Gschwantler M (1998) Patients’ assessment and recall of surgical information after laparoscopic cholecystectomy. Dig Surg. 15: 669-673. .

There are several studies that deal with the level of expectations depending on the type of information received [12], Gahndi R, Davey JR, Mahomed N (2009) Patient expectations predict greater pain relief with joint arthroplasty. J Arthroplasty 24(5): 716-721.[13], Muniesa JM, Marco E, Tejero M, Boza R, Duarte E , et al (2010) Analysis of the expectations of elderly patients before undergoing total knee replacement. Arch Gerontol Geriatr 51(3): e83-e87.[14], Mancuso CA, Sculco TP, Salvati EA (2003) Patients with poor preoperative functional status have high expectations of total hip arthroplasty. J Arthroplasty 18(7): 872-878.[17] Hepinsall MS, Ratledge JR, Bornstein LJ, Mazumdar M, Westrich GH (2011) Factors that impact expectations before total knee arthroplasty. 26(6): 870-876. . Other studies, like ours, have evaluated the difference in expectations before and after receiving a single type of information sharing method [4] Leal-Blanquet J, Alentorn-Geli E, Ginés-Cespedosa A, Martínez-Díaz S, Cáceres E, et al (2013) Effects of an educational audiovisual videodisc on patients’ pre-operative expectations with total knee arthroplasty: a prospective randomized comparative study. Knee Surg Sports Traumatol Arthrosc 21: 2595-2602.. It is probably necessary, in future studies, to compare the change in expectations before and after the information depending on the different types of information sharing method. It might also be interesting to assess how the combination of the different information systems might influence the final results and expectations.

In conclusion, the overall preoperative expectations relative to the postoperative results of total knee arthroplasty were not modified by the audiovisual information. In addition, it was not possible to identify a patient biophysical profile for which the intervention might be most effective. Based on these results, this complementary tool may not be systematically recommended, and, therefore, direct contact with the patient at the clinical visit is still the most important factor in influencing in the patient’s outlook [4] Leal-Blanquet J, Alentorn-Geli E, Ginés-Cespedosa A, Martínez-Díaz S, Cáceres E, et al (2013) Effects of an educational audiovisual videodisc on patients’ pre-operative expectations with total knee arthroplasty: a prospective randomized comparative study. Knee Surg Sports Traumatol Arthrosc 21: 2595-2602..